401k Plan data: GRAYSON MILL ENERGY, LLC WRAP WELFARE PLAN plan

GRAYSON MILL ENERGY, LLC WRAP WELFARE PLAN 401k Plan overview

Plan Name	GRAYSON MILL ENERGY, LLC WRAP WELFARE PLAN
Plan identification number	501

GRAYSON MILL ENERGY, LLC WRAP WELFARE 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)

401k Sponsoring company profile

GRAYSON MILL OPERATING, LLC has sponsored the creation of one or more 401k plans.

Company Name: GRAYSON MILL OPERATING, LLC

Employer identification number (EIN): 320508676

NAIC Classification: 324190

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GRAYSON MILL ENERGY, LLC WRAP WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 ANGELA SMITH 2023-08-28

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	ANGELA SMITH	2023-08-28

Plan Statistics for GRAYSON MILL ENERGY, LLC WRAP WELFARE PLAN

401k plan membership statisitcs for GRAYSON MILL ENERGY, LLC WRAP WELFARE PLAN

Measure Date Value
2022: GRAYSON MILL ENERGY, LLC WRAP WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 177
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 177
Number of employers contributing to the scheme 2022-01-01 0

Measure	Date	Value
2022: GRAYSON MILL ENERGY, LLC WRAP WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	177
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	177
Number of employers contributing to the scheme	2022-01-01	0

Form 5500 Responses for GRAYSON MILL ENERGY, LLC WRAP WELFARE PLAN

2022: GRAYSON MILL ENERGY, LLC WRAP WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	First time form 5500 has been submitted	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

323987

Policy instance

Insurance contract or identification number	323987
Number of Individuals Covered	503
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $142,649
Total amount of fees paid to insurance company	USD $3,495
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,846,348
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $142,649
Amount paid for insurance broker fees	3495
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

914305

Policy instance

Insurance contract or identification number	914305
Number of Individuals Covered	157
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,198
Total amount of fees paid to insurance company	USD $853
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,323
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,198
Amount paid for insurance broker fees	853
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

914303

Policy instance

Insurance contract or identification number	914303
Number of Individuals Covered	177
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $42,744
Total amount of fees paid to insurance company	USD $8,549
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $213,722
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $42,744
Amount paid for insurance broker fees	8549
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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Company Name:	GRAYSON MILL OPERATING, LLC
Employer identification number (EIN):	320508676
NAIC Classification:	324190