401k Plan data: AUTO COMPANY XXI WELFARE BENEFIT PLAN plan

AUTO COMPANY XXI WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	AUTO COMPANY XXI WELFARE BENEFIT PLAN
Plan identification number	502

AUTO COMPANY XXI WELFARE BENEFIT PLAN Benefits

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

AUTO COMPANY XXI, INC. has sponsored the creation of one or more 401k plans.

Company Name: AUTO COMPANY XXI, INC.

Employer identification number (EIN): 464541577

NAIC Classification: 441110
NAIC Description: New Car Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AUTO COMPANY XXI WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2014-11-01 B. GENE CLAYTON B. GENE CLAYTON 2015-07-24

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2014-11-01	B. GENE CLAYTON		B. GENE CLAYTON	2015-07-24

Plan Statistics for AUTO COMPANY XXI WELFARE BENEFIT PLAN

401k plan membership statisitcs for AUTO COMPANY XXI WELFARE BENEFIT PLAN

Measure Date Value
2014: AUTO COMPANY XXI WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-11-01 325
Total number of active participants reported on line 7a of the Form 5500 2014-11-01 0
Number of retired or separated participants receiving benefits 2014-11-01 0
Number of other retired or separated participants entitled to future benefits 2014-11-01 0
Total of all active and inactive participants 2014-11-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-11-01 0

Measure	Date	Value
2014: AUTO COMPANY XXI WELFARE BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-11-01	325
Total number of active participants reported on line 7a of the Form 5500	2014-11-01	0
Number of retired or separated participants receiving benefits	2014-11-01	0
Number of other retired or separated participants entitled to future benefits	2014-11-01	0
Total of all active and inactive participants	2014-11-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-11-01	0

Form 5500 Responses for AUTO COMPANY XXI WELFARE BENEFIT PLAN

2014: AUTO COMPANY XXI WELFARE BENEFIT PLAN 2014 form 5500 responses
2014-11-01	Type of plan entity	Single employer plan
2014-11-01	First time form 5500 has been submitted	Yes
2014-11-01	Submission has been amended	No
2014-11-01	This submission is the final filing	Yes
2014-11-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2014-11-01	Plan is a collectively bargained plan	No
2014-11-01	Plan funding arrangement – Insurance	Yes
2014-11-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )

Policy contract number

5121300

Policy instance

Insurance contract or identification number	5121300
Number of Individuals Covered	25
Insurance policy start date	2014-11-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 $31,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

GROUP HEALTH COOPERATIVE (National Association of Insurance Commissioners NAIC id number: 95672 )

Policy contract number

1420600 1420700

Policy instance

Insurance contract or identification number	1420600 1420700
Number of Individuals Covered	226
Insurance policy start date	2014-11-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 $191,816
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF WASHINGTON (National Association of Insurance Commissioners NAIC id number: 47341 )

Policy contract number

837

Policy instance

Insurance contract or identification number	837
Number of Individuals Covered	258
Insurance policy start date	2014-11-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $839
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $839
Insurance broker organization code?	3
Insurance broker name	WALLER BENEFITS CONSULTING LLC

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

G111-62A

Policy instance

Insurance contract or identification number	G111-62A
Number of Individuals Covered	130
Insurance policy start date	2014-11-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, CANCER, STD
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 $22,391
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

284450

Policy instance

Insurance contract or identification number	284450
Number of Individuals Covered	3
Insurance policy start date	2014-11-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	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 $261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )

Policy contract number

56627

Policy instance

Insurance contract or identification number	56627
Number of Individuals Covered	293
Insurance policy start date	2014-11-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ADD
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 $10,559
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	AUTO COMPANY XXI, INC.
Employer identification number (EIN):	464541577
NAIC Classification:	441110
NAIC Description:	New Car Dealers