401k Plan data: THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN plan

THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN
Plan identification number	502

THE PROVIDENCE GROUPS - HEALTH & 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)

401k Sponsoring company profile

THE PROVIDENCE GROUPS has sponsored the creation of one or more 401k plans.

Company Name: THE PROVIDENCE GROUPS

Employer identification number (EIN): 473117697

NAIC Classification: 541600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2021-09-01
502 2020-09-01 GREG MITCHELL 2022-03-25
502 2019-09-01 GRETCHEN COX 2021-02-16

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
502	2021-09-01
502	2020-09-01	GREG MITCHELL	2022-03-25
502	2019-09-01	GRETCHEN COX	2021-02-16

Plan Statistics for THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN

401k plan membership statisitcs for THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN

Measure Date Value
2021: THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-09-01 391
Total number of active participants reported on line 7a of the Form 5500 2021-09-01 371
Number of retired or separated participants receiving benefits 2021-09-01 0
Number of other retired or separated participants entitled to future benefits 2021-09-01 7
Total of all active and inactive participants 2021-09-01 378
2020: THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-09-01 269
Total number of active participants reported on line 7a of the Form 5500 2020-09-01 315
Number of retired or separated participants receiving benefits 2020-09-01 0
Number of other retired or separated participants entitled to future benefits 2020-09-01 0
Total of all active and inactive participants 2020-09-01 315
Number of employers contributing to the scheme 2020-09-01 0
2019: THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-09-01 359
Total number of active participants reported on line 7a of the Form 5500 2019-09-01 269
Number of retired or separated participants receiving benefits 2019-09-01 0
Number of other retired or separated participants entitled to future benefits 2019-09-01 0
Total of all active and inactive participants 2019-09-01 269
Number of employers contributing to the scheme 2019-09-01 0

Measure	Date	Value
2021: THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-09-01	391
Total number of active participants reported on line 7a of the Form 5500	2021-09-01	371
Number of retired or separated participants receiving benefits	2021-09-01	0
Number of other retired or separated participants entitled to future benefits	2021-09-01	7
Total of all active and inactive participants	2021-09-01	378
2020: THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-09-01	269
Total number of active participants reported on line 7a of the Form 5500	2020-09-01	315
Number of retired or separated participants receiving benefits	2020-09-01	0
Number of other retired or separated participants entitled to future benefits	2020-09-01	0
Total of all active and inactive participants	2020-09-01	315
Number of employers contributing to the scheme	2020-09-01	0
2019: THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-09-01	359
Total number of active participants reported on line 7a of the Form 5500	2019-09-01	269
Number of retired or separated participants receiving benefits	2019-09-01	0
Number of other retired or separated participants entitled to future benefits	2019-09-01	0
Total of all active and inactive participants	2019-09-01	269
Number of employers contributing to the scheme	2019-09-01	0

Form 5500 Responses for THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN

2021: THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN 2021 form 5500 responses
2021-09-01	Type of plan entity	Single employer plan
2021-09-01	Submission has been amended	No
2021-09-01	This submission is the final filing	No
2021-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-09-01	Plan is a collectively bargained plan	No
2021-09-01	Plan funding arrangement – Insurance	Yes
2021-09-01	Plan benefit arrangement – Insurance	Yes
2020: THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN 2020 form 5500 responses
2020-09-01	Type of plan entity	Single employer plan
2020-09-01	Plan funding arrangement – Insurance	Yes
2020-09-01	Plan benefit arrangement – Insurance	Yes
2019: THE PROVIDENCE GROUPS - HEALTH & WELFARE PLAN 2019 form 5500 responses
2019-09-01	Type of plan entity	Single employer plan
2019-09-01	First time form 5500 has been submitted	Yes
2019-09-01	Plan funding arrangement – Insurance	Yes
2019-09-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

140428

Policy instance

Insurance contract or identification number	140428
Number of Individuals Covered	154
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $59,980
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	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 $1,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,816
Insurance broker organization code?	3

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

Policy contract number

00564670

Policy instance

Insurance contract or identification number	00564670
Number of Individuals Covered	326
Insurance policy start date	2021-09-01
Insurance policy end date	2022-08-31
Total amount of commissions paid to insurance broker	USD $93,548
Total amount of fees paid to insurance company	USD $10,264
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	Yes
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	ACCIDENT, AD&D, OPTIONAL LIFE, VOLUNTARY CRITICAL ILLNESS, VOLUNTARY HOSPITAL INDEMNITY
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 $241,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,159
Amount paid for insurance broker fees	10264
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

140428

Policy instance

Insurance contract or identification number	140428
Number of Individuals Covered	192
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $56,584
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,354
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $56,295
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

564670

Policy instance

Insurance contract or identification number	564670
Number of Individuals Covered	315
Insurance policy start date	2020-09-01
Insurance policy end date	2021-08-31
Total amount of commissions paid to insurance broker	USD $33,869
Total amount of fees paid to insurance company	USD $3,171
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $180,114
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $33,868
Amount paid for insurance broker fees	3171
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )

Policy contract number

140428

Policy instance

Insurance contract or identification number	140428
Number of Individuals Covered	154
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $42,386
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,216
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,459
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

564670

Policy instance

Insurance contract or identification number	564670
Number of Individuals Covered	291
Insurance policy start date	2019-09-01
Insurance policy end date	2020-08-31
Total amount of commissions paid to insurance broker	USD $63,484
Total amount of fees paid to insurance company	USD $2,335
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $199,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,877
Amount paid for insurance broker fees	2335
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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Company Name:	THE PROVIDENCE GROUPS
Employer identification number (EIN):	473117697
NAIC Classification:	541600