401k Plan data: THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN plan

THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN 401k Plan overview

Plan Name	THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN
Plan identification number	501

THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision

401k Sponsoring company profile

THREE CROWNS PARK has sponsored the creation of one or more 401k plans.

Company Name: THREE CROWNS PARK

Employer identification number (EIN): 362030089

NAIC Classification: 541990
NAIC Description: All Other Professional, Scientific, and Technical Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-04-01
501 2019-04-01

Plan Statistics for THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN

401k plan membership statisitcs for THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN

Measure Date Value
2020: THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN 2020 401k membership
Total participants, beginning-of-year 2020-04-01 93
Total number of active participants reported on line 7a of the Form 5500 2020-04-01 106
Total of all active and inactive participants 2020-04-01 106
Total participants 2020-04-01 106
2019: THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN 2019 401k membership
Total participants, beginning-of-year 2019-04-01 100
Total number of active participants reported on line 7a of the Form 5500 2019-04-01 93
Total of all active and inactive participants 2019-04-01 93
Total participants 2019-04-01 93
Number of participants with account balances 2019-04-01 0

Measure	Date	Value
2020: THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN 2020 401k membership
Total participants, beginning-of-year	2020-04-01	93
Total number of active participants reported on line 7a of the Form 5500	2020-04-01	106
Total of all active and inactive participants	2020-04-01	106
Total participants	2020-04-01	106
2019: THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN 2019 401k membership
Total participants, beginning-of-year	2019-04-01	100
Total number of active participants reported on line 7a of the Form 5500	2019-04-01	93
Total of all active and inactive participants	2019-04-01	93
Total participants	2019-04-01	93
Number of participants with account balances	2019-04-01	0

Form 5500 Responses for THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN

2020: THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN 2020 form 5500 responses
2020-04-01	Type of plan entity	Single employer plan
2020-04-01	Submission has been amended	No
2020-04-01	This submission is the final filing	No
2020-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-04-01	Plan is a collectively bargained plan	No
2020-04-01	Plan funding arrangement – Insurance	Yes
2020-04-01	Plan benefit arrangement – Insurance	Yes
2019: THREE CROWNS PARK MEDICAL, DENTAL AND VISION PLAN 2019 form 5500 responses
2019-04-01	Type of plan entity	Single employer plan
2019-04-01	Plan funding arrangement – Insurance	Yes
2019-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

00560823

Policy instance

Insurance contract or identification number	00560823
Number of Individuals Covered	85
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $4,747
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 $47,475
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,747
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

99568481001

Policy instance

Insurance contract or identification number	99568481001
Number of Individuals Covered	116
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $757
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 $7,669
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $757
Insurance broker organization code?	3

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

Policy contract number

265887

Policy instance

Insurance contract or identification number	265887
Number of Individuals Covered	98
Insurance policy start date	2020-04-01
Insurance policy end date	2021-03-31
Total amount of commissions paid to insurance broker	USD $31,193
Total amount of fees paid to insurance company	USD $693
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 $777,751
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,193
Amount paid for insurance broker fees	693
Additional information about fees paid to insurance broker	SPECIAL PROGRAMS
Insurance broker organization code?	3

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

Policy contract number

560823

Policy instance

Insurance contract or identification number	560823
Number of Individuals Covered	79
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $4,547
Total amount of fees paid to insurance company	USD $1,390
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $45,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,547
Amount paid for insurance broker fees	1390
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	4

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

99568481001

Policy instance

Insurance contract or identification number	99568481001
Number of Individuals Covered	89
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $733
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,258
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $733
Insurance broker organization code?	4

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

Policy contract number

Policy instance

Number of Individuals Covered	90
Insurance policy start date	2019-04-01
Insurance policy end date	2020-03-31
Total amount of commissions paid to insurance broker	USD $31,468
Total amount of fees paid to insurance company	USD $765
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $783,379
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $31,468
Amount paid for insurance broker fees	765
Additional information about fees paid to insurance broker	SPERCIAL PROGRAM
Insurance broker organization code?	4

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Company Name:	THREE CROWNS PARK
Employer identification number (EIN):	362030089
NAIC Classification:	541990
NAIC Description:	All Other Professional, Scientific, and Technical Services