401k Plan data: KEB AMERICA INC ANCILLARY BENEFITS PLAN plan

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KEB AMERICA INC ANCILLARY BENEFITS PLAN 401k Plan overview

Plan Name	KEB AMERICA INC ANCILLARY BENEFITS PLAN
Plan identification number	501

KEB AMERICA INC ANCILLARY BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Dental Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

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

Company Name: KEB AMERICA, INC.

Employer identification number (EIN): 411348864

NAIC Classification: 335900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KEB AMERICA INC ANCILLARY BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01
501 2021-01-01

Plan Statistics for KEB AMERICA INC ANCILLARY BENEFITS PLAN

401k plan membership statisitcs for KEB AMERICA INC ANCILLARY BENEFITS PLAN

Measure Date Value
2022: KEB AMERICA INC ANCILLARY BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 106
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 102
Total of all active and inactive participants 2022-01-01 102
Total participants 2022-01-01 102
2021: KEB AMERICA INC ANCILLARY BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 119
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 106
Total of all active and inactive participants 2021-01-01 106
Total participants 2021-01-01 106

Form 5500 Responses for KEB AMERICA INC ANCILLARY BENEFITS PLAN

2022: KEB AMERICA INC ANCILLARY BENEFITS PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: KEB AMERICA INC ANCILLARY BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	First time form 5500 has been submitted	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0AMQ5

Policy instance

1

Insurance contract or identification number	GLTD0AMQ5
Number of Individuals Covered	102
Total amount of commissions paid to insurance broker	USD $3,005
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,036
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,005
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AMQ5

Policy instance

2

Insurance contract or identification number	GLUG0AMQ5
Number of Individuals Covered	102
Total amount of commissions paid to insurance broker	USD $1,247
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $8,314
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,247
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDS0AMQ5

Policy instance

3

Insurance contract or identification number	GUDS0AMQ5
Number of Individuals Covered	76
Total amount of commissions paid to insurance broker	USD $6,537
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $65,374
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,537
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUG 0AMQ5

Policy instance

4

Insurance contract or identification number	GUG 0AMQ5
Number of Individuals Covered	101
Total amount of commissions paid to insurance broker	USD $3,032
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $20,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,032
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLTD0AMQ5

Policy instance

1

Insurance contract or identification number	GLTD0AMQ5
Number of Individuals Covered	105
Total amount of commissions paid to insurance broker	USD $3,153
Total amount of fees paid to insurance company	USD $1,482
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,017
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,701
Insurance broker organization code?	3
Amount paid for insurance broker fees	1482
Additional information about fees paid to insurance broker	OTHER COMPENSATION

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLU0AMQ5

Policy instance

2

Insurance contract or identification number	GLU0AMQ5
Number of Individuals Covered	106
Total amount of commissions paid to insurance broker	USD $1,488
Total amount of fees paid to insurance company	USD $741
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $9,921
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $748
Insurance broker organization code?	3
Amount paid for insurance broker fees	741
Additional information about fees paid to insurance broker	OTHER COMPENSASTION

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