401k Plan data: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN plan

FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 401k Plan overview

Plan Name	FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN
Plan identification number	002

FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

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.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
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.

401k Sponsoring company profile

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

Company Name: FORSBERGS, INC.

Employer identification number (EIN): 410656530

NAIC Classification: 333200

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2022-01-01 CARNA VON HOLTUM 2023-09-22
002 2021-01-01 CARNA VON HOLTUM 2022-06-28 CARNA VON HOLTUM 2022-06-28
002 2020-01-01 CARNA VON HOLTUM 2021-10-14 CARNA VON HOLTUM 2021-10-14
002 2019-01-01 CARNA VON HOLTUM 2020-08-26 DENNY BAKKE 2020-08-26
002 2018-01-01 CARNA VON HOLTUM 2019-07-31 DENNY BAKKE 2019-07-31
002 2017-01-01 CARNA VON HOLTUM 2018-10-05 DENNY 2018-10-05
002 2016-01-01 CARNA VON HOLTUM 2017-07-27 DENNY BAKKE 2017-07-27
002 2015-01-01 CARNA VON HOLTUM 2016-07-29 CARNA VON HOLTUM 2016-07-29
002 2014-01-01 CARNA VON HOLTUM DENNY BAKKE 2015-07-29
002 2013-01-01 CARNA VON HOLTUM DENNIS BAKKE 2014-07-24
002 2012-01-01 CARNA VON HOLTUM DENNIS BAKKE 2013-06-26
002 2011-01-01 CARNA VON HOLTUM
002 2009-01-01 DEEDEE JOHNSON DENNY BAKKE 2010-07-27

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
002	2022-01-01	CARNA VON HOLTUM	2023-09-22
002	2021-01-01	CARNA VON HOLTUM	2022-06-28	CARNA VON HOLTUM	2022-06-28
002	2020-01-01	CARNA VON HOLTUM	2021-10-14	CARNA VON HOLTUM	2021-10-14
002	2019-01-01	CARNA VON HOLTUM	2020-08-26	DENNY BAKKE	2020-08-26
002	2018-01-01	CARNA VON HOLTUM	2019-07-31	DENNY BAKKE	2019-07-31
002	2017-01-01	CARNA VON HOLTUM	2018-10-05	DENNY	2018-10-05
002	2016-01-01	CARNA VON HOLTUM	2017-07-27	DENNY BAKKE	2017-07-27
002	2015-01-01	CARNA VON HOLTUM	2016-07-29	CARNA VON HOLTUM	2016-07-29
002	2014-01-01	CARNA VON HOLTUM		DENNY BAKKE	2015-07-29
002	2013-01-01	CARNA VON HOLTUM		DENNIS BAKKE	2014-07-24
002	2012-01-01	CARNA VON HOLTUM		DENNIS BAKKE	2013-06-26
002	2011-01-01	CARNA VON HOLTUM
002	2009-01-01	DEEDEE JOHNSON		DENNY BAKKE	2010-07-27

Plan Statistics for FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN

401k plan membership statisitcs for FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN

Measure Date Value
2014: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 30
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 28
Number of retired or separated participants receiving benefits 2014-01-01 1
Number of other retired or separated participants entitled to future benefits 2014-01-01 3
Total of all active and inactive participants 2014-01-01 32
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 32
Number of participants with account balances 2014-01-01 32
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 30
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 26
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 4
Total of all active and inactive participants 2013-01-01 30
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 30
Number of participants with account balances 2013-01-01 30
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 30
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 28
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 4
Total of all active and inactive participants 2012-01-01 32
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 32
Number of participants with account balances 2012-01-01 28
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 32
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 30
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 2
Total of all active and inactive participants 2011-01-01 32
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 32
Number of participants with account balances 2011-01-01 32
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2009: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 33
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 31
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 0
Total of all active and inactive participants 2009-01-01 31
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 31
Number of participants with account balances 2009-01-01 31
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 1

Measure	Date	Value
2014: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	30
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	28
Number of retired or separated participants receiving benefits	2014-01-01	1
Number of other retired or separated participants entitled to future benefits	2014-01-01	3
Total of all active and inactive participants	2014-01-01	32
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	32
Number of participants with account balances	2014-01-01	32
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	30
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	26
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	4
Total of all active and inactive participants	2013-01-01	30
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	30
Number of participants with account balances	2013-01-01	30
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	30
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	28
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	4
Total of all active and inactive participants	2012-01-01	32
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	32
Number of participants with account balances	2012-01-01	28
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	32
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	30
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	2
Total of all active and inactive participants	2011-01-01	32
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	32
Number of participants with account balances	2011-01-01	32
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2009: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	33
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	31
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	0
Total of all active and inactive participants	2009-01-01	31
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	31
Number of participants with account balances	2009-01-01	31
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	1

Financial Data on FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN

Measure	Date	Value
2014 : FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2014 401k financial data
Transfers to/from the plan	2014-12-31	$0
Total income from all sources	2014-12-31	$237,205
Expenses. Total of all expenses incurred	2014-12-31	$190,892
Benefits paid (including direct rollovers)	2014-12-31	$190,399
Total plan assets at end of year	2014-12-31	$1,725,184
Total plan assets at beginning of year	2014-12-31	$1,678,871
Value of fidelity bond covering the plan	2014-12-31	$150,000
Total contributions received or receivable from participants	2014-12-31	$67,170
Expenses. Other expenses not covered elsewhere	2014-12-31	$493
Contributions received from other sources (not participants or employers)	2014-12-31	$0
Other income received	2014-12-31	$90,643
Net income (gross income less expenses)	2014-12-31	$46,313
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$1,725,184
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$1,678,871
Assets. Value of participant loans	2014-12-31	$51,127
Total contributions received or receivable from employer(s)	2014-12-31	$79,392
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2014-12-31	$0
Minimum employer required contribution for this plan year	2014-12-31	$0
Amount contributed by the employer to the plan for this plan year	2014-12-31	$0
2013 : FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2013 401k financial data
Transfers to/from the plan	2013-12-31	$0
Total income from all sources	2013-12-31	$338,677
Expenses. Total of all expenses incurred	2013-12-31	$73,059
Benefits paid (including direct rollovers)	2013-12-31	$72,619
Total plan assets at end of year	2013-12-31	$1,678,871
Total plan assets at beginning of year	2013-12-31	$1,413,253
Value of fidelity bond covering the plan	2013-12-31	$150,000
Total contributions received or receivable from participants	2013-12-31	$59,576
Expenses. Other expenses not covered elsewhere	2013-12-31	$440
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$207,829
Net income (gross income less expenses)	2013-12-31	$265,618
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$1,678,871
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$1,413,253
Assets. Value of participant loans	2013-12-31	$61,104
Total contributions received or receivable from employer(s)	2013-12-31	$71,272
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2013-12-31	$0
Minimum employer required contribution for this plan year	2013-12-31	$0
Amount contributed by the employer to the plan for this plan year	2013-12-31	$0
2012 : FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2012 401k financial data
Transfers to/from the plan	2012-12-31	$0
Total income from all sources	2012-12-31	$287,313
Expenses. Total of all expenses incurred	2012-12-31	$115,226
Benefits paid (including direct rollovers)	2012-12-31	$114,494
Total plan assets at end of year	2012-12-31	$1,413,253
Total plan assets at beginning of year	2012-12-31	$1,241,166
Value of fidelity bond covering the plan	2012-12-31	$150,000
Total contributions received or receivable from participants	2012-12-31	$64,900
Expenses. Other expenses not covered elsewhere	2012-12-31	$732
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$150,756
Net income (gross income less expenses)	2012-12-31	$172,087
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$1,413,253
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$1,241,166
Assets. Value of participant loans	2012-12-31	$61,275
Total contributions received or receivable from employer(s)	2012-12-31	$71,657
Value of certain deemed distributions of participant loans	2012-12-31	$0
Value of corrective distributions	2012-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2012-12-31	$0
Minimum employer required contribution for this plan year	2012-12-31	$0
Amount contributed by the employer to the plan for this plan year	2012-12-31	$0
2011 : FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2011 401k financial data
Transfers to/from the plan	2011-12-31	$0
Total income from all sources	2011-12-31	$160,043
Expenses. Total of all expenses incurred	2011-12-31	$201,005
Benefits paid (including direct rollovers)	2011-12-31	$200,593
Total plan assets at end of year	2011-12-31	$1,241,166
Total plan assets at beginning of year	2011-12-31	$1,282,128
Value of fidelity bond covering the plan	2011-12-31	$150,000
Total contributions received or receivable from participants	2011-12-31	$79,573
Expenses. Other expenses not covered elsewhere	2011-12-31	$412
Contributions received from other sources (not participants or employers)	2011-12-31	$0
Other income received	2011-12-31	$-2,170
Net income (gross income less expenses)	2011-12-31	$-40,962
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$1,241,166
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$1,282,128
Assets. Value of participant loans	2011-12-31	$48,460
Total contributions received or receivable from employer(s)	2011-12-31	$82,640
Value of certain deemed distributions of participant loans	2011-12-31	$0
Value of corrective distributions	2011-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2011-12-31	$0
Minimum employer required contribution for this plan year	2011-12-31	$0
Amount contributed by the employer to the plan for this plan year	2011-12-31	$0
2009 : FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2009 401k financial data
Funding deficiency by the employer to the plan for this plan year	2009-12-31	$0
Minimum employer required contribution for this plan year	2009-12-31	$0
Amount contributed by the employer to the plan for this plan year	2009-12-31	$0

Form 5500 Responses for FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN

2014: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: FORSBERGS, INC. 401(K) SALARY REDUCTION PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-822553

Policy instance

Insurance contract or identification number	GA-822553
Number of Individuals Covered	32
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $4,987
Total amount of fees paid to insurance company	USD $0
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?	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 $4,987
Insurance broker organization code?	3
Insurance broker name	EDWARD D JONES & CO L P.

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-822553

Policy instance

Insurance contract or identification number	GA-822553
Number of Individuals Covered	30
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,266
Total amount of fees paid to insurance company	USD $0
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?	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 $4,266
Insurance broker organization code?	3
Insurance broker name	EDWARD D JONES & CO

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-822553

Policy instance

Insurance contract or identification number	GA-822553
Number of Individuals Covered	28
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $3,727
Total amount of fees paid to insurance company	USD $0
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?	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 $3,727
Insurance broker organization code?	3
Insurance broker name	EDWARD D JONES & CO

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-822553

Policy instance

Insurance contract or identification number	GA-822553
Number of Individuals Covered	32
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $3,639
Total amount of fees paid to insurance company	USD $0
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?	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

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Company Name:	FORSBERGS, INC.
Employer identification number (EIN):	410656530
NAIC Classification:	333200