401k Plan data: INTERNATIONAL CITY MORTGAGE HEALTH AND WELFARE PLAN plan

INTERNATIONAL CITY MORTGAGE HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	INTERNATIONAL CITY MORTGAGE HEALTH AND WELFARE PLAN
Plan identification number	501

INTERNATIONAL CITY MORTGAGE HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance 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.

401k Sponsoring company profile

INTERNATIONAL CITY MORTGAGE has sponsored the creation of one or more 401k plans.

Company Name: INTERNATIONAL CITY MORTGAGE

Employer identification number (EIN): 330231744

NAIC Classification: 522292
NAIC Description: Real Estate Credit

Form 5500 Filing Information

Submission information for form 5500 for 401k plan INTERNATIONAL CITY MORTGAGE HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-07-01 DANIELLE BOREN 2022-12-02

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-07-01	DANIELLE BOREN	2022-12-02

Plan Statistics for INTERNATIONAL CITY MORTGAGE HEALTH AND WELFARE PLAN

401k plan membership statisitcs for INTERNATIONAL CITY MORTGAGE HEALTH AND WELFARE PLAN

Measure Date Value
2021: INTERNATIONAL CITY MORTGAGE HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-07-01 100
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 73
Number of retired or separated participants receiving benefits 2021-07-01 0
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 73
Number of employers contributing to the scheme 2021-07-01 0

Measure	Date	Value
2021: INTERNATIONAL CITY MORTGAGE HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-07-01	100
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	73
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	73
Number of employers contributing to the scheme	2021-07-01	0

Form 5500 Responses for INTERNATIONAL CITY MORTGAGE HEALTH AND WELFARE PLAN

2021: INTERNATIONAL CITY MORTGAGE HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	First time form 5500 has been submitted	Yes
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

231645

Policy instance

Insurance contract or identification number	231645
Number of Individuals Covered	14
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $10,040
Total amount of fees paid to insurance company	USD $144
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $197,745
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,040
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

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

Policy contract number

7105

Policy instance

Insurance contract or identification number	7105
Number of Individuals Covered	4
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $758
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,251
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $758
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

924533

Policy instance

Insurance contract or identification number	924533
Number of Individuals Covered	43
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $24,793
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $539,692
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,793
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

169053

Policy instance

Insurance contract or identification number	169053
Number of Individuals Covered	73
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $6,585
Total amount of fees paid to insurance company	USD $1,035
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $68,111
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,585
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION

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Company Name:	INTERNATIONAL CITY MORTGAGE
Employer identification number (EIN):	330231744
NAIC Classification:	522292
NAIC Description:	Real Estate Credit