401k Plan data: CARBON LIGHTHOUSE, INC. plan

CARBON LIGHTHOUSE, INC. 401k Plan overview

Plan Name	CARBON LIGHTHOUSE, INC.
Plan identification number	501

CARBON LIGHTHOUSE, INC. Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision Long-term disability cover Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

CARBON LIGHTHOUSE INC has sponsored the creation of one or more 401k plans.

Company Name: CARBON LIGHTHOUSE INC

Employer identification number (EIN): 273261836

NAIC Classification: 541600

Additional information about CARBON LIGHTHOUSE INC

Jurisdiction of Incorporation: California Department of State

Incorporation Date:

Company Identification Number: 201020410181

More information about CARBON LIGHTHOUSE INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CARBON LIGHTHOUSE, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-12-01

Plan Statistics for CARBON LIGHTHOUSE, INC.

401k plan membership statisitcs for CARBON LIGHTHOUSE, INC.

Measure Date Value
2019: CARBON LIGHTHOUSE, INC. 2019 401k membership
Total participants, beginning-of-year 2019-12-01 115
Total number of active participants reported on line 7a of the Form 5500 2019-12-01 60
Number of retired or separated participants receiving benefits 2019-12-01 1
Number of other retired or separated participants entitled to future benefits 2019-12-01 0
Total of all active and inactive participants 2019-12-01 61

Measure	Date	Value
2019: CARBON LIGHTHOUSE, INC. 2019 401k membership
Total participants, beginning-of-year	2019-12-01	115
Total number of active participants reported on line 7a of the Form 5500	2019-12-01	60
Number of retired or separated participants receiving benefits	2019-12-01	1
Number of other retired or separated participants entitled to future benefits	2019-12-01	0
Total of all active and inactive participants	2019-12-01	61

Form 5500 Responses for CARBON LIGHTHOUSE, INC.

2019: CARBON LIGHTHOUSE, INC. 2019 form 5500 responses
2019-12-01	Type of plan entity	Single employer plan
2019-12-01	First time form 5500 has been submitted	Yes
2019-12-01	Submission has been amended	No
2019-12-01	This submission is the final filing	No
2019-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-12-01	Plan is a collectively bargained plan	No
2019-12-01	Plan funding arrangement – Insurance	Yes
2019-12-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1101987

Policy instance

Insurance contract or identification number	1101987
Number of Individuals Covered	112
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $10,483
Total amount of fees paid to insurance company	USD $2,308
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $94,062
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0085405

Policy instance

Insurance contract or identification number	W0085405
Number of Individuals Covered	82
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $25,409
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $432,786
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

715402

Policy instance

Insurance contract or identification number	715402
Number of Individuals Covered	50
Insurance policy start date	2019-12-01
Insurance policy end date	2020-11-30
Total amount of commissions paid to insurance broker	USD $13,217
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $280,472
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CARBON LIGHTHOUSE INC
Employer identification number (EIN):	273261836
NAIC Classification:	541600

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	201020410181