401k Plan data: ARCHON BUSINESS GROUP BENEFIT WELFARE PLAN plan

ARCHON BUSINESS GROUP BENEFIT WELFARE PLAN 401k Plan overview

Plan Name	ARCHON BUSINESS GROUP BENEFIT WELFARE PLAN
Plan identification number	501

ARCHON BUSINESS GROUP BENEFIT WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

ARCHON BUSINESS SOLUTIONS has sponsored the creation of one or more 401k plans.

Company Name: ARCHON BUSINESS SOLUTIONS

Employer identification number (EIN): 460544351

NAIC Classification: 621320
NAIC Description: Offices of Optometrists

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ARCHON BUSINESS GROUP BENEFIT WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-09-01 LINDA MOORE 2023-06-05

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2021-09-01	LINDA MOORE	2023-06-05

Plan Statistics for ARCHON BUSINESS GROUP BENEFIT WELFARE PLAN

401k plan membership statisitcs for ARCHON BUSINESS GROUP BENEFIT WELFARE PLAN

Measure Date Value
2021: ARCHON BUSINESS GROUP BENEFIT WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-09-01 140
Total number of active participants reported on line 7a of the Form 5500 2021-09-01 153
Number of retired or separated participants receiving benefits 2021-09-01 1
Number of other retired or separated participants entitled to future benefits 2021-09-01 0
Total of all active and inactive participants 2021-09-01 154
Number of employers contributing to the scheme 2021-09-01 0

Measure	Date	Value
2021: ARCHON BUSINESS GROUP BENEFIT WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-09-01	140
Total number of active participants reported on line 7a of the Form 5500	2021-09-01	153
Number of retired or separated participants receiving benefits	2021-09-01	1
Number of other retired or separated participants entitled to future benefits	2021-09-01	0
Total of all active and inactive participants	2021-09-01	154
Number of employers contributing to the scheme	2021-09-01	0

Form 5500 Responses for ARCHON BUSINESS GROUP BENEFIT WELFARE PLAN

2021: ARCHON BUSINESS GROUP BENEFIT WELFARE PLAN 2021 form 5500 responses
2021-09-01	Type of plan entity	Single employer plan
2021-09-01	First time form 5500 has been submitted	Yes
2021-09-01	Plan funding arrangement – Insurance	Yes
2021-09-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

876772

Policy instance

Insurance contract or identification number	876772
Number of Individuals Covered	23
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $2,413
Total amount of fees paid to insurance company	USD $422
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,129
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,413
Amount paid for insurance broker fees	422
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

GEM50

Policy instance

Insurance contract or identification number	GEM50
Number of Individuals Covered	21
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $1,407
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $14,257
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $815
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0003627

Policy instance

Insurance contract or identification number	W0003627
Number of Individuals Covered	108
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $47,223
Total amount of fees paid to insurance company	USD $0
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
Welfare Benefit Premiums Paid to Carrier	USD $795,012
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,223
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

407006

Policy instance

Insurance contract or identification number	407006
Number of Individuals Covered	153
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $3,963
Total amount of fees paid to insurance company	USD $501
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	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $28,642
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,963
Amount paid for insurance broker fees	501
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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Company Name:	ARCHON BUSINESS SOLUTIONS
Employer identification number (EIN):	460544351
NAIC Classification:	621320
NAIC Description:	Offices of Optometrists