401k Plan data: OSI ENVIRONMENTAL, INC. 401K PLAN plan

OSI ENVIRONMENTAL, INC. 401K PLAN 401k Plan overview

Plan Name	OSI ENVIRONMENTAL, INC. 401K PLAN
Plan identification number	002

OSI ENVIRONMENTAL, INC. 401K PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

OSI ENVIRONMENTAL, INC. has sponsored the creation of one or more 401k plans.

Company Name: OSI ENVIRONMENTAL, INC.

Employer identification number (EIN): 391611741

NAIC Classification: 324110
NAIC Description: Petroleum Refineries

Additional information about OSI ENVIRONMENTAL, INC.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2013-12-05

Company Identification Number: 0801893640

Legal Registered Office Address: 912 TESCH CT

WAUKESHA
United States of America (USA)
53186

More information about OSI ENVIRONMENTAL, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OSI ENVIRONMENTAL, INC. 401K PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2022-01-01 GARY GROHOLSKI 2023-08-16
002 2021-01-01 GARY GROHOLSKI 2022-08-24
002 2020-01-01 GARY GROHOLSKI 2021-09-09
002 2018-01-01
002 2017-01-01
002 2016-01-01 DIANE BORGWARDT 2017-07-05
002 2015-01-01 DIANE BORGWARDT 2016-08-02
002 2014-01-01 DIANE BORGWARDT 2015-04-30
002 2013-01-01 DIANE BORGWARDT 2014-03-25 DIANE BORGWARDT 2014-03-25
002 2012-01-01 DIANE BORGWARDT 2013-06-07 DIANE BORGWARDT 2013-06-07
002 2011-01-01 DIANE BORGWARDT 2012-03-28 DIANE BORGWARDT 2012-03-28
002 2010-01-01 SHIRLEY BRANER 2011-04-27 SHIRLEY BRANER 2011-04-27

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
002	2022-01-01	GARY GROHOLSKI	2023-08-16
002	2021-01-01	GARY GROHOLSKI	2022-08-24
002	2020-01-01	GARY GROHOLSKI	2021-09-09
002	2018-01-01
002	2017-01-01
002	2016-01-01	DIANE BORGWARDT	2017-07-05
002	2015-01-01	DIANE BORGWARDT	2016-08-02
002	2014-01-01	DIANE BORGWARDT	2015-04-30
002	2013-01-01	DIANE BORGWARDT	2014-03-25	DIANE BORGWARDT	2014-03-25
002	2012-01-01	DIANE BORGWARDT	2013-06-07	DIANE BORGWARDT	2013-06-07
002	2011-01-01	DIANE BORGWARDT	2012-03-28	DIANE BORGWARDT	2012-03-28
002	2010-01-01	SHIRLEY BRANER	2011-04-27	SHIRLEY BRANER	2011-04-27

Plan Statistics for OSI ENVIRONMENTAL, INC. 401K PLAN

401k plan membership statisitcs for OSI ENVIRONMENTAL, INC. 401K PLAN

Measure Date Value
2022: OSI ENVIRONMENTAL, INC. 401K PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 105
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 11
Total of all active and inactive participants 2022-01-01 116
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 116
Number of participants with account balances 2022-01-01 94
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: OSI ENVIRONMENTAL, INC. 401K PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 107
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 10
Total of all active and inactive participants 2021-01-01 117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 117
Number of participants with account balances 2021-01-01 94
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 4
2020: OSI ENVIRONMENTAL, INC. 401K PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 125
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 115
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 9
Total of all active and inactive participants 2020-01-01 124
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 124
Number of participants with account balances 2020-01-01 97
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 3

Measure	Date	Value
2022: OSI ENVIRONMENTAL, INC. 401K PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	105
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	11
Total of all active and inactive participants	2022-01-01	116
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	116
Number of participants with account balances	2022-01-01	94
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: OSI ENVIRONMENTAL, INC. 401K PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	107
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	10
Total of all active and inactive participants	2021-01-01	117
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	117
Number of participants with account balances	2021-01-01	94
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	4
2020: OSI ENVIRONMENTAL, INC. 401K PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	125
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	115
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	9
Total of all active and inactive participants	2020-01-01	124
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	124
Number of participants with account balances	2020-01-01	97
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	3

Financial Data on OSI ENVIRONMENTAL, INC. 401K PLAN

Measure	Date	Value
2022 : OSI ENVIRONMENTAL, INC. 401K PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$-1,327,047
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$482,316
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$420,369
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$616,450
Value of total assets at end of year	2022-12-31	$11,310,077
Value of total assets at beginning of year	2022-12-31	$13,119,440
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$61,947
Total interest from all sources	2022-12-31	$7,744
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$0
Administrative expenses professional fees incurred	2022-12-31	$61,947
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$500,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$390,354
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2022-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2022-12-31	$0
Total non interest bearing cash at end of year	2022-12-31	$738
Total non interest bearing cash at beginning of year	2022-12-31	$4,902
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-1,809,363
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$11,310,077
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$13,119,440
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in pooled separate accounts at end of year	2022-12-31	$10,430,781
Value of interest in pooled separate accounts at beginning of year	2022-12-31	$12,074,779
Interest earned on other investments	2022-12-31	$7,744
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$647,560
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$805,256
Net investment gain/loss from pooled separate accounts	2022-12-31	$-1,951,241
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$226,096
Employer contributions (assets) at end of year	2022-12-31	$230,998
Employer contributions (assets) at beginning of year	2022-12-31	$234,503
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$420,369
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	VRAKAS S.C
Accountancy firm EIN	2022-12-31	391453055
2021 : OSI ENVIRONMENTAL, INC. 401K PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$9,584
Total income from all sources (including contributions)	2021-12-31	$2,167,995
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$2,588,671
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$2,517,072
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$765,474
Value of total assets at end of year	2021-12-31	$13,119,440
Value of total assets at beginning of year	2021-12-31	$13,549,700
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$71,599
Total interest from all sources	2021-12-31	$10,420
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Administrative expenses professional fees incurred	2021-12-31	$71,599
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$500,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$414,050
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$116,921
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2021-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2021-12-31	$9,584
Total non interest bearing cash at end of year	2021-12-31	$4,902
Total non interest bearing cash at beginning of year	2021-12-31	$5,648
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$-420,676
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$13,119,440
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$13,540,116
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in pooled separate accounts at end of year	2021-12-31	$12,074,779
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$12,495,260
Interest earned on other investments	2021-12-31	$10,420
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$805,256
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$801,964
Net investment gain/loss from pooled separate accounts	2021-12-31	$1,392,101
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$234,503
Employer contributions (assets) at end of year	2021-12-31	$234,503
Employer contributions (assets) at beginning of year	2021-12-31	$246,828
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$2,517,072
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	VRAKAS S.C
Accountancy firm EIN	2021-12-31	391453055
2020 : OSI ENVIRONMENTAL, INC. 401K PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$9,584
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$2,362,870
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$1,252,378
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$1,174,178
Value of total corrective distributions	2020-12-31	$9,584
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$690,606
Value of total assets at end of year	2020-12-31	$13,549,700
Value of total assets at beginning of year	2020-12-31	$12,429,624
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$68,616
Total interest from all sources	2020-12-31	$10,800
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
Administrative expenses professional fees incurred	2020-12-31	$68,616
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$500,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$443,778
Total non interest bearing cash at end of year	2020-12-31	$5,648
Total non interest bearing cash at beginning of year	2020-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$1,110,492
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$13,540,116
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$12,429,624
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in pooled separate accounts at end of year	2020-12-31	$12,495,260
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$12,177,980
Interest earned on other investments	2020-12-31	$10,800
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$801,964
Net investment gain/loss from pooled separate accounts	2020-12-31	$1,661,464
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$246,828
Employer contributions (assets) at end of year	2020-12-31	$246,828
Employer contributions (assets) at beginning of year	2020-12-31	$251,644
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$1,174,178
Liabilities. Value of benefit claims payable at end of year	2020-12-31	$9,584
Did the plan have assets held for investment	2020-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Unqualified
Accountancy firm name	2020-12-31	VRAKAS S.C
Accountancy firm EIN	2020-12-31	391453055

Form 5500 Responses for OSI ENVIRONMENTAL, INC. 401K PLAN

2022: OSI ENVIRONMENTAL, INC. 401K PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: OSI ENVIRONMENTAL, INC. 401K PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: OSI ENVIRONMENTAL, INC. 401K PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

21965

Policy instance

Insurance contract or identification number	21965
Number of Individuals Covered	101
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $29,140
Total amount of fees paid to insurance company	USD $7,475
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
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,309
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	BROKER COMMISSION
Insurance broker organization code?	3

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

21965

Policy instance

Insurance contract or identification number	21965
Number of Individuals Covered	99
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $32,358
Total amount of fees paid to insurance company	USD $5,495
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
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $25,882
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	BROKER COMMISSION
Insurance broker organization code?	3

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

21965

Policy instance

Insurance contract or identification number	21965
Number of Individuals Covered	102
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $29,675
Total amount of fees paid to insurance company	USD $5,488
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?	Yes
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
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $23,737
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	TPA COMPENSATION

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Company Name:	OSI ENVIRONMENTAL, INC.
Employer identification number (EIN):	391611741
NAIC Classification:	324110
NAIC Description:	Petroleum Refineries

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2013-12-05
Company Identification Number:	0801893640
Legal Registered Office Address:	912 TESCH CT WAUKESHA United States of America (USA) 53186