401k Plan data: STAFFORD'S HOSPITALITY INC WELFARE BENEFIT PLAN plan

STAFFORD'S HOSPITALITY INC WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	STAFFORD'S HOSPITALITY INC WELFARE BENEFIT PLAN
Plan identification number	503

STAFFORD'S HOSPITALITY INC 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) Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

STAFFORD'S HOSPITALITY, INC. has sponsored the creation of one or more 401k plans.

Company Name: STAFFORD'S HOSPITALITY, INC.

Employer identification number (EIN): 381853758

NAIC Classification: 721110
NAIC Description: Hotels (except Casino Hotels) and Motels

Form 5500 Filing Information

Submission information for form 5500 for 401k plan STAFFORD'S HOSPITALITY INC WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2021-12-01 BRIAN EWBANK 2023-08-30

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
503	2021-12-01	BRIAN EWBANK	2023-08-30

Plan Statistics for STAFFORD'S HOSPITALITY INC WELFARE BENEFIT PLAN

401k plan membership statisitcs for STAFFORD'S HOSPITALITY INC WELFARE BENEFIT PLAN

Measure Date Value
2021: STAFFORD'S HOSPITALITY INC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-12-01 108
Total number of active participants reported on line 7a of the Form 5500 2021-12-01 101
Number of retired or separated participants receiving benefits 2021-12-01 0
Number of other retired or separated participants entitled to future benefits 2021-12-01 0
Total of all active and inactive participants 2021-12-01 101
Number of employers contributing to the scheme 2021-12-01 0

Measure	Date	Value
2021: STAFFORD'S HOSPITALITY INC WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-12-01	108
Total number of active participants reported on line 7a of the Form 5500	2021-12-01	101
Number of retired or separated participants receiving benefits	2021-12-01	0
Number of other retired or separated participants entitled to future benefits	2021-12-01	0
Total of all active and inactive participants	2021-12-01	101
Number of employers contributing to the scheme	2021-12-01	0

Form 5500 Responses for STAFFORD'S HOSPITALITY INC WELFARE BENEFIT PLAN

2021: STAFFORD'S HOSPITALITY INC WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-12-01	Type of plan entity	Single employer plan
2021-12-01	First time form 5500 has been submitted	Yes
2021-12-01	Plan funding arrangement – Insurance	Yes
2021-12-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

PRIORITY HEALTH (National Association of Insurance Commissioners NAIC id number: 95561 )

Policy contract number

792789

Policy instance

Insurance contract or identification number	792789
Number of Individuals Covered	65
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $12,626
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $304,685
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,626
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

2352

Policy instance

Insurance contract or identification number	2352
Number of Individuals Covered	67
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $1,895
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,895
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

12264018

Policy instance

Insurance contract or identification number	12264018
Number of Individuals Covered	50
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $763
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $9,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $715
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10247364

Policy instance

Insurance contract or identification number	10247364
Number of Individuals Covered	103
Insurance policy start date	2021-12-01
Insurance policy end date	2022-11-30
Total amount of commissions paid to insurance broker	USD $4,531
Total amount of fees paid to insurance company	USD $820
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $42,211
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,494
Amount paid for insurance broker fees	588
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

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Company Name:	STAFFORD'S HOSPITALITY, INC.
Employer identification number (EIN):	381853758
NAIC Classification:	721110
NAIC Description:	Hotels (except Casino Hotels) and Motels