401k Plan data: LUXE VALET, INC. HEALTH AND WELFARE PLAN plan

LUXE VALET, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	LUXE VALET, INC. HEALTH AND WELFARE PLAN
Plan identification number	501

LUXE VALET, INC. HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

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

Company Name: LUXE VALET, INC.

Employer identification number (EIN): 463278407

NAIC Classification: 485990

Additional information about LUXE VALET, INC.

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division

Incorporation Date: 2015-04-23

Company Identification Number: 603499784

Legal Registered Office Address: 111 S JACKSON ST

SEATTLE
United States of America (USA)
981040000

More information about LUXE VALET, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LUXE VALET, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-01-01

Plan Statistics for LUXE VALET, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for LUXE VALET, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2017: LUXE VALET, INC. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 276
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 0
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 0

Measure	Date	Value
2017: LUXE VALET, INC. HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	276
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	0
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	0

Form 5500 Responses for LUXE VALET, INC. HEALTH AND WELFARE PLAN

2017: LUXE VALET, INC. 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	Yes
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
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

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

85468

Policy instance

Insurance contract or identification number	85468
Number of Individuals Covered	29
Insurance policy start date	2017-01-01
Insurance policy end date	2017-09-30
Total amount of commissions paid to insurance broker	USD $6,420
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	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 $64,197
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,420
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

CONCERN EAP (National Association of Insurance Commissioners NAIC id number: 16165 )

Policy contract number

Policy instance

Insurance contract or identification number	00
Number of Individuals Covered	14
Insurance policy start date	2017-01-01
Insurance policy end date	2017-09-30
Total amount of commissions paid to insurance broker	USD $143
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	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
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
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 $2,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $143
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

246858

Policy instance

Insurance contract or identification number	246858
Number of Individuals Covered	18
Insurance policy start date	2017-01-01
Insurance policy end date	2017-09-30
Total amount of commissions paid to insurance broker	USD $1,942
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	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
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 $14,578
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,942
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

280901

Policy instance

Insurance contract or identification number	280901
Number of Individuals Covered	38
Insurance policy start date	2017-01-01
Insurance policy end date	2017-09-30
Total amount of commissions paid to insurance broker	USD $15,632
Total amount of fees paid to insurance company	USD $510
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 $287,708
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,632
Amount paid for insurance broker fees	510
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30071620

Policy instance

Insurance contract or identification number	30071620
Number of Individuals Covered	16
Insurance policy start date	2017-01-01
Insurance policy end date	2017-09-30
Total amount of commissions paid to insurance broker	USD $820
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	No
Vision Insurance Welfare Benefit	Yes
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 $11,972
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $820
Insurance broker organization code?	3
Insurance broker name	ALLIANT INSURANCE SERVICES, INC.

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Company Name:	LUXE VALET, INC.
Employer identification number (EIN):	463278407
NAIC Classification:	485990

Jurisdiction of Incorporation:	Washington Secretary of State Corporations Division
Incorporation Date:	2015-04-23
Company Identification Number:	603499784
Legal Registered Office Address:	111 S JACKSON ST SEATTLE United States of America (USA) 981040000