401k Plan data: WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN plan

WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN
Plan identification number	502

WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision 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. Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

WOODBRIDGE GLASS, INC. / WERNER SYSTEMS, INC. has sponsored the creation of one or more 401k plans.

Company Name: WOODBRIDGE GLASS, INC. / WERNER SYSTEMS, INC.

Employer identification number (EIN): 330118109

NAIC Classification: 238900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2021-12-01
502 2020-12-01
502 2009-06-01 VIRGINIA SICILIANI

Plan Statistics for WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN

Measure Date Value
2021: WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-12-01 120
Total number of active participants reported on line 7a of the Form 5500 2021-12-01 86
Number of retired or separated participants receiving benefits 2021-12-01 0
Number of other retired or separated participants entitled to future benefits 2021-12-01 0
Total of all active and inactive participants 2021-12-01 86
2020: WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-12-01 124
Total number of active participants reported on line 7a of the Form 5500 2020-12-01 120
Number of retired or separated participants receiving benefits 2020-12-01 0
Number of other retired or separated participants entitled to future benefits 2020-12-01 0
Total of all active and inactive participants 2020-12-01 120
2009: WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-06-01 94
Total number of active participants reported on line 7a of the Form 5500 2009-06-01 65
Number of retired or separated participants receiving benefits 2009-06-01 5
Number of other retired or separated participants entitled to future benefits 2009-06-01 10
Total of all active and inactive participants 2009-06-01 80
Total participants 2009-06-01 80

Measure	Date	Value
2021: WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-12-01	120
Total number of active participants reported on line 7a of the Form 5500	2021-12-01	86
Number of retired or separated participants receiving benefits	2021-12-01	0
Number of other retired or separated participants entitled to future benefits	2021-12-01	0
Total of all active and inactive participants	2021-12-01	86
2020: WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-12-01	124
Total number of active participants reported on line 7a of the Form 5500	2020-12-01	120
Number of retired or separated participants receiving benefits	2020-12-01	0
Number of other retired or separated participants entitled to future benefits	2020-12-01	0
Total of all active and inactive participants	2020-12-01	120
2009: WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-06-01	94
Total number of active participants reported on line 7a of the Form 5500	2009-06-01	65
Number of retired or separated participants receiving benefits	2009-06-01	5
Number of other retired or separated participants entitled to future benefits	2009-06-01	10
Total of all active and inactive participants	2009-06-01	80
Total participants	2009-06-01	80

Form 5500 Responses for WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN

2021: WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-12-01	Type of plan entity	Single employer plan
2021-12-01	Submission has been amended	No
2021-12-01	This submission is the final filing	No
2021-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-12-01	Plan is a collectively bargained plan	No
2021-12-01	Plan funding arrangement – Insurance	Yes
2021-12-01	Plan benefit arrangement – Insurance	Yes
2020: WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-12-01	Type of plan entity	Single employer plan
2020-12-01	Submission has been amended	No
2020-12-01	This submission is the final filing	No
2020-12-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-12-01	Plan is a collectively bargained plan	No
2020-12-01	Plan funding arrangement – Insurance	Yes
2020-12-01	Plan benefit arrangement – Insurance	Yes
2009: WOODBRIDGE GLASS, INC./WERNER SYSTEMS, INC. HEALTH AND WELFARE EMPLOYEE BENEFITS PLAN 2009 form 5500 responses
2009-06-01	Type of plan entity	Single employer plan
2009-06-01	Plan funding arrangement – Insurance	Yes
2009-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

L03893

Policy instance

Insurance contract or identification number	L03893
Number of Individuals Covered	86
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $34,342
Total amount of fees paid to insurance company	USD $7,023
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 $747,837
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $34,342
Amount paid for insurance broker fees	7023
Additional information about fees paid to insurance broker	INCENTIVES, EDUCATION, COMMUNICATION AND TRAINING
Insurance broker organization code?	3

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

903798

Policy instance

Insurance contract or identification number	903798
Number of Individuals Covered	84
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $4,455
Total amount of fees paid to insurance company	USD $590
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	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 $57,952
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,455
Amount paid for insurance broker fees	590
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5734948

Policy instance

Insurance contract or identification number	5734948
Number of Individuals Covered	123
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $1,193
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	Yes
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 $12,074
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,093
Insurance broker organization code?	3

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00623 )

Policy contract number

LB473A

Policy instance

Insurance contract or identification number	LB473A
Number of Individuals Covered	125
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $37,975
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 $831,802
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,975
Insurance broker organization code?	3

SAFEGUARD HEALTH PLANS, INC. A CALIFORNIA CORPORATION (National Association of Insurance Commissioners NAIC id number: 96030 )

Policy contract number

5734948

Policy instance

Insurance contract or identification number	5734948
Number of Individuals Covered	102
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $2,935
Total amount of fees paid to insurance company	USD $90
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	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 $19,961
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,798
Insurance broker organization code?	3
Amount paid for insurance broker fees	90
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

903798

Policy instance

Insurance contract or identification number	903798
Number of Individuals Covered	40
Insurance policy start date	2020-12-01
Insurance policy end date	2021-11-30
Total amount of commissions paid to insurance broker	USD $2,364
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	Yes
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 $40,248
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,119
Insurance broker organization code?	3

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Company Name:	WOODBRIDGE GLASS, INC. / WERNER SYSTEMS, INC.
Employer identification number (EIN):	330118109
NAIC Classification:	238900