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| Plan Name | REVOLUTION GLOBAL STAFFING, LLC HEALTH & WELFARE PROGRAM |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | REVOLUTION GLOBAL STAFFING, LLC |
| Employer identification number (EIN): | 464102558 |
| NAIC Classification: | 111900 |
| NAIC Description: | Other Crop Farming |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2021-05-01 | CRAIG J. JOHNSON | 2023-02-01 | ||
| 501 | 2020-05-01 | JENNIFER MARSZALEK | 2021-12-15 |
| Measure | Date | Value |
|---|---|---|
| 2021: REVOLUTION GLOBAL STAFFING, LLC HEALTH & WELFARE PROGRAM 2021 401k membership | ||
| Total participants, beginning-of-year | 2021-05-01 | 149 |
| Total number of active participants reported on line 7a of the Form 5500 | 2021-05-01 | 149 |
| Number of retired or separated participants receiving benefits | 2021-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2021-05-01 | 0 |
| Total of all active and inactive participants | 2021-05-01 | 149 |
| Number of employers contributing to the scheme | 2021-05-01 | 0 |
| 2020: REVOLUTION GLOBAL STAFFING, LLC HEALTH & WELFARE PROGRAM 2020 401k membership | ||
| Total participants, beginning-of-year | 2020-05-01 | 171 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-05-01 | 149 |
| Number of retired or separated participants receiving benefits | 2020-05-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-05-01 | 0 |
| Total of all active and inactive participants | 2020-05-01 | 149 |
| 2021: REVOLUTION GLOBAL STAFFING, LLC HEALTH & WELFARE PROGRAM 2021 form 5500 responses | ||
|---|---|---|
| 2021-05-01 | Type of plan entity | Single employer plan |
| 2021-05-01 | Plan funding arrangement – Insurance | Yes |
| 2021-05-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2021-05-01 | Plan benefit arrangement – Insurance | Yes |
| 2021-05-01 | Plan benefit arrangement – General assets of the sponsor | Yes |
| 2020: REVOLUTION GLOBAL STAFFING, LLC HEALTH & WELFARE PROGRAM 2020 form 5500 responses | ||
| 2020-05-01 | Type of plan entity | Single employer plan |
| 2020-05-01 | First time form 5500 has been submitted | Yes |
| 2020-05-01 | Submission has been amended | No |
| 2020-05-01 | This submission is the final filing | No |
| 2020-05-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2020-05-01 | Plan is a collectively bargained plan | No |
| 2020-05-01 | Plan funding arrangement – Insurance | Yes |
| 2020-05-01 | Plan benefit arrangement – Insurance | Yes |
| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 164421 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | F025376 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 5953715 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | F025376 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 164900 B64421 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 3 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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