401k Plan data: DRAWBRIDGE, INC. HEALTH AND WELFARE BENEFITS PLAN plan

DRAWBRIDGE, INC. HEALTH AND WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	DRAWBRIDGE, INC. HEALTH AND WELFARE BENEFITS PLAN
Plan identification number	501

DRAWBRIDGE, INC. HEALTH AND WELFARE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit 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

DRAWBRIDGE, INC. has sponsored the creation of one or more 401k plans.

Company Name: DRAWBRIDGE, INC.

Employer identification number (EIN): 273484607

NAIC Classification: 541600

Additional information about DRAWBRIDGE, INC.

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1995-11-09

Company Identification Number: 1972128

Legal Registered Office Address: 7935 BOSTON STATE RD
Erie
HAMBURG
United States of America (USA)
140757306

More information about DRAWBRIDGE, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DRAWBRIDGE, INC. HEALTH AND WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-09-01

Plan Statistics for DRAWBRIDGE, INC. HEALTH AND WELFARE BENEFITS PLAN

401k plan membership statisitcs for DRAWBRIDGE, INC. HEALTH AND WELFARE BENEFITS PLAN

Measure Date Value
2017: DRAWBRIDGE, INC. HEALTH AND WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-09-01 159
Total number of active participants reported on line 7a of the Form 5500 2017-09-01 83
Number of retired or separated participants receiving benefits 2017-09-01 0
Number of other retired or separated participants entitled to future benefits 2017-09-01 0
Total of all active and inactive participants 2017-09-01 83

Measure	Date	Value
2017: DRAWBRIDGE, INC. HEALTH AND WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-09-01	159
Total number of active participants reported on line 7a of the Form 5500	2017-09-01	83
Number of retired or separated participants receiving benefits	2017-09-01	0
Number of other retired or separated participants entitled to future benefits	2017-09-01	0
Total of all active and inactive participants	2017-09-01	83

Form 5500 Responses for DRAWBRIDGE, INC. HEALTH AND WELFARE BENEFITS PLAN

2017: DRAWBRIDGE, INC. HEALTH AND WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-09-01	Type of plan entity	Single employer plan
2017-09-01	First time form 5500 has been submitted	Yes
2017-09-01	Submission has been amended	No
2017-09-01	This submission is the final filing	No
2017-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-09-01	Plan is a collectively bargained plan	No
2017-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-09-01	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

1080038

Policy instance

Insurance contract or identification number	1080038
Number of Individuals Covered	83
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $12,049
Total amount of fees paid to insurance company	USD $8,778
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	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
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 $172,038
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

605593

Policy instance

Insurance contract or identification number	605593
Number of Individuals Covered	69
Insurance policy start date	2017-09-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,396
Total amount of fees paid to insurance company	USD $2
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 $143,850
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

W0064926

Policy instance

Insurance contract or identification number	W0064926
Number of Individuals Covered	37
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $40,764
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 $815,288
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

RELIASTAR LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67105 )

Policy contract number

70183-1

Policy instance

Insurance contract or identification number	70183-1
Number of Individuals Covered	18
Insurance policy start date	2017-09-01
Insurance policy end date	2018-08-31
Total amount of commissions paid to insurance broker	USD $2,445
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	No
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
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS AND HOSPITAL CONFINEMENT
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 $12,228
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	DRAWBRIDGE, INC.
Employer identification number (EIN):	273484607
NAIC Classification:	541600

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1995-11-09
Company Identification Number:	1972128
Legal Registered Office Address:	7935 BOSTON STATE RD Erie HAMBURG United States of America (USA) 140757306