401k Plan data: TERRY'S TIRE TOWN CAFETERIA PLAN plan

TERRY'S TIRE TOWN CAFETERIA PLAN 401k Plan overview

Plan Name	TERRY'S TIRE TOWN CAFETERIA PLAN
Plan identification number	501

TERRY'S TIRE TOWN CAFETERIA PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Vision Long-term disability cover

401k Sponsoring company profile

TERRYS TIRE TOWN, INC. has sponsored the creation of one or more 401k plans.

Company Name: TERRYS TIRE TOWN, INC.

Employer identification number (EIN): 341260171

NAIC Classification: 811190

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TERRY'S TIRE TOWN CAFETERIA PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2012-01-01 HILLARY JOHNSTON
501 2011-01-01 THOMAS E. FIALA

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2012-01-01	HILLARY JOHNSTON
501	2011-01-01	THOMAS E. FIALA

Plan Statistics for TERRY'S TIRE TOWN CAFETERIA PLAN

401k plan membership statisitcs for TERRY'S TIRE TOWN CAFETERIA PLAN

Measure Date Value
2012: TERRY'S TIRE TOWN CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 510
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 520
Total of all active and inactive participants 2012-01-01 520
2011: TERRY'S TIRE TOWN CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 286
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 510
Total of all active and inactive participants 2011-01-01 510

Measure	Date	Value
2012: TERRY'S TIRE TOWN CAFETERIA PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	510
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	520
Total of all active and inactive participants	2012-01-01	520
2011: TERRY'S TIRE TOWN CAFETERIA PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	286
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	510
Total of all active and inactive participants	2011-01-01	510

Form 5500 Responses for TERRY'S TIRE TOWN CAFETERIA PLAN

2012: TERRY'S TIRE TOWN CAFETERIA PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: TERRY'S TIRE TOWN CAFETERIA PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00169087

Policy instance

Insurance contract or identification number	00169087
Number of Individuals Covered	452
Insurance policy start date	2011-07-01
Insurance policy end date	2012-06-30
Total amount of commissions paid to insurance broker	USD $60,892
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,565,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $60,892
Insurance broker organization code?	3
Insurance broker name	TODD ASSOCIATES, INC.

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00471989

Policy instance

Insurance contract or identification number	00471989
Number of Individuals Covered	520
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $19,301
Total amount of fees paid to insurance company	USD $775
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $166,541
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,108
Amount paid for insurance broker fees	775
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	TODD ASSOCIATES, INC.

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

CD3781,CP3782

Policy instance

Insurance contract or identification number	CD3781,CP3782
Number of Individuals Covered	328
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $12,876
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $151,892
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,876
Insurance broker organization code?	3
Insurance broker name	TODD ASSOCIATES, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12263880

Policy instance

Insurance contract or identification number	12263880
Number of Individuals Covered	276
Insurance policy start date	2011-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,517
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $85,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,517
Insurance broker organization code?	3
Insurance broker name	TODD ASSOCIATES, INC.

COMMUNITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 10345 )

Policy contract number

00169087

Policy instance

Insurance contract or identification number	00169087
Number of Individuals Covered	420
Insurance policy start date	2010-07-01
Insurance policy end date	2011-06-30
Total amount of commissions paid to insurance broker	USD $60,892
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,565,276
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

5446866

Policy instance

Insurance contract or identification number	5446866
Number of Individuals Covered	466
Insurance policy start date	2010-09-01
Insurance policy end date	2011-08-31
Total amount of commissions paid to insurance broker	USD $10,531
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $74,878
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

CD3781,CP3782

Policy instance

Insurance contract or identification number	CD3781,CP3782
Number of Individuals Covered	319
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,244
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $99,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47029 )

Policy contract number

12263880

Policy instance

Insurance contract or identification number	12263880
Number of Individuals Covered	272
Insurance policy start date	2010-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $2,823
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $59,482
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	TERRYS TIRE TOWN, INC.
Employer identification number (EIN):	341260171
NAIC Classification:	811190