401k Plan data: TANOS EXPLORATION II, LLC HEALTH AND WELFARE PLAN plan

TANOS EXPLORATION II, LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	TANOS EXPLORATION II, LLC HEALTH AND WELFARE PLAN
Plan identification number	502

TANOS EXPLORATION II, LLC HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental

401k Sponsoring company profile

TANOS EXPLORATION II, LLC has sponsored the creation of one or more 401k plans.

Company Name: TANOS EXPLORATION II, LLC

Employer identification number (EIN): 432213294

NAIC Classification: 211110
NAIC Description: Oil and Gas Extraction, Oil

Additional information about TANOS EXPLORATION II, LLC

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2013-03-06

Company Identification Number: 0801745202

Legal Registered Office Address: 821 E SOUTHEAST LOOP 323 STE 400

TYLER
United States of America (USA)
75701

More information about TANOS EXPLORATION II, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan TANOS EXPLORATION II, LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2017-01-01

Plan Statistics for TANOS EXPLORATION II, LLC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for TANOS EXPLORATION II, LLC HEALTH AND WELFARE PLAN

Measure Date Value
2017: TANOS EXPLORATION II, LLC HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 106
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 121
Number of retired or separated participants receiving benefits 2017-01-01 1
Number of other retired or separated participants entitled to future benefits 2017-01-01 1
Total of all active and inactive participants 2017-01-01 123

Measure	Date	Value
2017: TANOS EXPLORATION II, LLC HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	106
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	121
Number of retired or separated participants receiving benefits	2017-01-01	1
Number of other retired or separated participants entitled to future benefits	2017-01-01	1
Total of all active and inactive participants	2017-01-01	123

Form 5500 Responses for TANOS EXPLORATION II, LLC HEALTH AND WELFARE PLAN

2017: TANOS EXPLORATION II, LLC HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	First time form 5500 has been submitted	Yes
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1024461

Policy instance

Insurance contract or identification number	1024461
Number of Individuals Covered	336
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $4,355
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	Yes
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 $117,674
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,896
Insurance broker organization code?	3
Insurance broker name	RANDALL SCOTT WARD

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

199818

Policy instance

Insurance contract or identification number	199818
Number of Individuals Covered	316
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $27,819
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	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 $1,339,327
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $27,819
Insurance broker organization code?	3
Insurance broker name	RANDALL SCOTT WARD

Potentially related plans

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Company Name:	TANOS EXPLORATION II, LLC
Employer identification number (EIN):	432213294
NAIC Classification:	211110
NAIC Description:	Oil and Gas Extraction, Oil

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2013-03-06
Company Identification Number:	0801745202
Legal Registered Office Address:	821 E SOUTHEAST LOOP 323 STE 400 TYLER United States of America (USA) 75701