401k Plan data: CONSUMER HEALTHCARE HEALTH AND WELFARE BENEFITS PLAN FOR PUERTO RICO EMPLOYEEES plan

CONSUMER HEALTHCARE HEALTH AND WELFARE BENEFITS PLAN FOR PUERTO RICO EMPLOYEEES 401k Plan overview

Plan Name	CONSUMER HEALTHCARE HEALTH AND WELFARE BENEFITS PLAN FOR PUERTO RICO EMPLOYEEES
Plan identification number	503

CONSUMER HEALTHCARE HEALTH AND WELFARE BENEFITS PLAN FOR PUERTO RICO EMPLOYEEES 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 Severance pay Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

GLAXOSMITHKLINE CONSUMER HEALTHCARE HOLDINGS (US), LLC has sponsored the creation of one or more 401k plans.

Company Name: GLAXOSMITHKLINE CONSUMER HEALTHCARE HOLDINGS (US), LLC

Employer identification number (EIN): 472931057

NAIC Classification: 325410

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CONSUMER HEALTHCARE HEALTH AND WELFARE BENEFITS PLAN FOR PUERTO RICO EMPLOYEEES

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2022-07-01

Plan Statistics for CONSUMER HEALTHCARE HEALTH AND WELFARE BENEFITS PLAN FOR PUERTO RICO EMPLOYEEES

401k plan membership statisitcs for CONSUMER HEALTHCARE HEALTH AND WELFARE BENEFITS PLAN FOR PUERTO RICO EMPLOYEEES

Measure Date Value
2022: CONSUMER HEALTHCARE HEALTH AND WELFARE BENEFITS PLAN FOR PUERTO RICO EMPLOYEEES 2022 401k membership
Total participants, beginning-of-year 2022-07-01 787
Total number of active participants reported on line 7a of the Form 5500 2022-07-01 851
Number of retired or separated participants receiving benefits 2022-07-01 2
Number of other retired or separated participants entitled to future benefits 2022-07-01 7
Total of all active and inactive participants 2022-07-01 860

Measure	Date	Value
2022: CONSUMER HEALTHCARE HEALTH AND WELFARE BENEFITS PLAN FOR PUERTO RICO EMPLOYEEES 2022 401k membership
Total participants, beginning-of-year	2022-07-01	787
Total number of active participants reported on line 7a of the Form 5500	2022-07-01	851
Number of retired or separated participants receiving benefits	2022-07-01	2
Number of other retired or separated participants entitled to future benefits	2022-07-01	7
Total of all active and inactive participants	2022-07-01	860

Form 5500 Responses for CONSUMER HEALTHCARE HEALTH AND WELFARE BENEFITS PLAN FOR PUERTO RICO EMPLOYEEES

2022: CONSUMER HEALTHCARE HEALTH AND WELFARE BENEFITS PLAN FOR PUERTO RICO EMPLOYEEES 2022 form 5500 responses
2022-07-01	Type of plan entity	Single employer plan
2022-07-01	First time form 5500 has been submitted	Yes
2022-07-01	Submission has been amended	No
2022-07-01	This submission is the final filing	No
2022-07-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2022-07-01	Plan is a collectively bargained plan	No
2022-07-01	Plan funding arrangement – Insurance	Yes
2022-07-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-07-01	Plan benefit arrangement – Insurance	Yes
2022-07-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10369451001

Policy instance

Insurance contract or identification number	10369451001
Number of Individuals Covered	1757
Insurance policy start date	2022-07-01
Insurance policy end date	2022-12-31
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PPC WORLDWIDE - OPTUM (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

16176

Policy instance

Insurance contract or identification number	16176
Number of Individuals Covered	897
Insurance policy start date	2022-07-01
Insurance policy end date	2022-12-31
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 $9,439
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

238395

Policy instance

Insurance contract or identification number	238395
Number of Individuals Covered	1776
Insurance policy start date	2022-07-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $834
Total amount of fees paid to insurance company	USD $1,419
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & 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 $124,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $834
Amount paid for insurance broker fees	1419
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3

ACE AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 22667 )

Policy contract number

N18140433

Policy instance

Insurance contract or identification number	N18140433
Number of Individuals Covered	827
Insurance policy start date	2022-07-01
Insurance policy end date	2022-12-31
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	BUSINESS TRAVEL ACCIDENT
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 $4,025
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10369471001

Policy instance

Insurance contract or identification number	10369471001
Number of Individuals Covered	4
Insurance policy start date	2022-07-01
Insurance policy end date	2022-12-31
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	GLAXOSMITHKLINE CONSUMER HEALTHCARE HOLDINGS (US), LLC
Employer identification number (EIN):	472931057
NAIC Classification:	325410