401k Plan data: LILLY DISTRIBUTION, LLC HEALTH AND WELFARE BENEFIT PLAN plan

LILLY DISTRIBUTION, LLC HEALTH AND WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	LILLY DISTRIBUTION, LLC HEALTH AND WELFARE BENEFIT PLAN
Plan identification number	502

LILLY DISTRIBUTION, LLC HEALTH AND WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) 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

LILLY DISTRIBUTION, LLC has sponsored the creation of one or more 401k plans.

Company Name: LILLY DISTRIBUTION, LLC

Employer identification number (EIN): 371878893

NAIC Classification: 312200
NAIC Description: Tobacco Manufacturing

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LILLY DISTRIBUTION, LLC HEALTH AND WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2019-04-01 JAN FLEDELIUS 2020-05-20

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2019-04-01	JAN FLEDELIUS	2020-05-20

Plan Statistics for LILLY DISTRIBUTION, LLC HEALTH AND WELFARE BENEFIT PLAN

401k plan membership statisitcs for LILLY DISTRIBUTION, LLC HEALTH AND WELFARE BENEFIT PLAN

Measure Date Value
2019: LILLY DISTRIBUTION, LLC HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-04-01 110
Total number of active participants reported on line 7a of the Form 5500 2019-04-01 33
Number of retired or separated participants receiving benefits 2019-04-01 0
Number of other retired or separated participants entitled to future benefits 2019-04-01 0
Total of all active and inactive participants 2019-04-01 33

Measure	Date	Value
2019: LILLY DISTRIBUTION, LLC HEALTH AND WELFARE BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-04-01	110
Total number of active participants reported on line 7a of the Form 5500	2019-04-01	33
Number of retired or separated participants receiving benefits	2019-04-01	0
Number of other retired or separated participants entitled to future benefits	2019-04-01	0
Total of all active and inactive participants	2019-04-01	33

Form 5500 Responses for LILLY DISTRIBUTION, LLC HEALTH AND WELFARE BENEFIT PLAN

2019: LILLY DISTRIBUTION, LLC HEALTH AND WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-04-01	Type of plan entity	Single employer plan
2019-04-01	Submission has been amended	No
2019-04-01	This submission is the final filing	No
2019-04-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2019-04-01	Plan is a collectively bargained plan	No
2019-04-01	Plan funding arrangement – Insurance	Yes
2019-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

618423

Policy instance

Insurance contract or identification number	618423
Number of Individuals Covered	22
Insurance policy start date	2019-04-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $123
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 $1,302
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $123
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

GYB52

Policy instance

Insurance contract or identification number	GYB52
Number of Individuals Covered	38
Insurance policy start date	2019-04-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $1,268
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	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY WORKSITE PLANS
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 $13,474
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,268
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1066366

Policy instance

Insurance contract or identification number	1066366
Number of Individuals Covered	51
Insurance policy start date	2019-04-01
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $1,311
Total amount of fees paid to insurance company	USD $317
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 $10,852
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,311
Amount paid for insurance broker fees	317
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

AVMED HEALTH PLANS (National Association of Insurance Commissioners NAIC id number: 95263 )

Policy contract number

128858

Policy instance

Insurance contract or identification number	128858
Number of Individuals Covered	55
Insurance policy start date	2019-04-02
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $15,484
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 $204,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,484
Insurance broker organization code?	3

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

Policy contract number

245957

Policy instance

Insurance contract or identification number	245957
Number of Individuals Covered	3
Insurance policy start date	2019-04-02
Insurance policy end date	2019-07-31
Total amount of commissions paid to insurance broker	USD $4,513
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	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 $23,352
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,513
Insurance broker organization code?	3

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Company Name:	LILLY DISTRIBUTION, LLC
Employer identification number (EIN):	371878893
NAIC Classification:	312200
NAIC Description:	Tobacco Manufacturing