401k Plan data: BLUE ACORN, LLC EMPLOYEE BENEFITS PLAN plan

BLUE ACORN, LLC EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	BLUE ACORN, LLC EMPLOYEE BENEFITS PLAN
Plan identification number	501

BLUE ACORN, LLC EMPLOYEE BENEFITS 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 Other welfare benefit cover

401k Sponsoring company profile

BLUE ACORN ICI, INC. has sponsored the creation of one or more 401k plans.

Company Name: BLUE ACORN ICI, INC.

Employer identification number (EIN): 384066461

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLUE ACORN, LLC EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-09-01

Plan Statistics for BLUE ACORN, LLC EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for BLUE ACORN, LLC EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: BLUE ACORN, LLC EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-09-01 287
Total number of active participants reported on line 7a of the Form 5500 2022-09-01 221
Number of retired or separated participants receiving benefits 2022-09-01 4
Number of other retired or separated participants entitled to future benefits 2022-09-01 0
Total of all active and inactive participants 2022-09-01 225

Measure	Date	Value
2022: BLUE ACORN, LLC EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-09-01	287
Total number of active participants reported on line 7a of the Form 5500	2022-09-01	221
Number of retired or separated participants receiving benefits	2022-09-01	4
Number of other retired or separated participants entitled to future benefits	2022-09-01	0
Total of all active and inactive participants	2022-09-01	225

Form 5500 Responses for BLUE ACORN, LLC EMPLOYEE BENEFITS PLAN

2022: BLUE ACORN, LLC EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-09-01	Type of plan entity	Single employer plan
2022-09-01	Submission has been amended	No
2022-09-01	This submission is the final filing	No
2022-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-09-01	Plan is a collectively bargained plan	No
2022-09-01	Plan funding arrangement – Insurance	Yes
2022-09-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

14171222-1001

Policy instance

Insurance contract or identification number	14171222-1001
Number of Individuals Covered	365
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $69,766
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	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 $2,001,753
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $69,766
Insurance broker organization code?	3

DELTA DENTAL OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54658 )

Policy contract number

10313

Policy instance

Insurance contract or identification number	10313
Number of Individuals Covered	343
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $11,345
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	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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,345
Insurance broker organization code?	3

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

01-020329

Policy instance

Insurance contract or identification number	01-020329
Number of Individuals Covered	221
Insurance policy start date	2022-09-01
Insurance policy end date	2023-08-31
Total amount of commissions paid to insurance broker	USD $16,778
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 $87,145
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,583
Insurance broker organization code?	3

Potentially related plans

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Company Name:	BLUE ACORN ICI, INC.
Employer identification number (EIN):	384066461