401k Plan data: BLACKHAWK MOLDING CO., INC. EMPLOYEE BENEFIT PLAN plan

BLACKHAWK MOLDING CO., INC. EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	BLACKHAWK MOLDING CO., INC. EMPLOYEE BENEFIT PLAN
Plan identification number	503

BLACKHAWK MOLDING CO., INC. EMPLOYEE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Dental Temporary disability (accident and sickness) Long-term disability cover

401k Sponsoring company profile

BLACKHAWK MOLDING COMPANY, INC. has sponsored the creation of one or more 401k plans.

Company Name: BLACKHAWK MOLDING COMPANY, INC.

Employer identification number (EIN): 362160077

NAIC Classification: 326100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLACKHAWK MOLDING CO., INC. EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2012-04-01 ROBERT HIDDING

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
503	2012-04-01	ROBERT HIDDING

Plan Statistics for BLACKHAWK MOLDING CO., INC. EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for BLACKHAWK MOLDING CO., INC. EMPLOYEE BENEFIT PLAN

Measure Date Value
2012: BLACKHAWK MOLDING CO., INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-04-01 185
Total number of active participants reported on line 7a of the Form 5500 2012-04-01 0
Number of retired or separated participants receiving benefits 2012-04-01 0
Number of other retired or separated participants entitled to future benefits 2012-04-01 0
Total of all active and inactive participants 2012-04-01 0

Measure	Date	Value
2012: BLACKHAWK MOLDING CO., INC. EMPLOYEE BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-04-01	185
Total number of active participants reported on line 7a of the Form 5500	2012-04-01	0
Number of retired or separated participants receiving benefits	2012-04-01	0
Number of other retired or separated participants entitled to future benefits	2012-04-01	0
Total of all active and inactive participants	2012-04-01	0

Form 5500 Responses for BLACKHAWK MOLDING CO., INC. EMPLOYEE BENEFIT PLAN

2012: BLACKHAWK MOLDING CO., INC. EMPLOYEE BENEFIT PLAN 2012 form 5500 responses
2012-04-01	Type of plan entity	Single employer plan
2012-04-01	First time form 5500 has been submitted	Yes
2012-04-01	Submission has been amended	No
2012-04-01	This submission is the final filing	Yes
2012-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-04-01	Plan is a collectively bargained plan	No
2012-04-01	Plan funding arrangement – Insurance	Yes
2012-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F1D0359

Policy instance

Insurance contract or identification number	F1D0359
Number of Individuals Covered	188
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $17,389
Total amount of fees paid to insurance company	USD $5,153
Are there contracts with allocated funds for individual policies?	No
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	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD & D
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 $183,629
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,389
Amount paid for insurance broker fees	5153
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	ASSURANCE AGENCY LTD

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Company Name:	BLACKHAWK MOLDING COMPANY, INC.
Employer identification number (EIN):	362160077
NAIC Classification:	326100