401k Plan data: CURTIS BAY ENERGY, INC plan

CURTIS BAY ENERGY, INC 401k Plan overview

Plan Name	CURTIS BAY ENERGY, INC
Plan identification number	502

CURTIS BAY ENERGY, INC 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

CURTIS BAY ENERGY, INC. has sponsored the creation of one or more 401k plans.

Company Name: CURTIS BAY ENERGY, INC.

Employer identification number (EIN): 521770031

NAIC Classification: 562000

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CURTIS BAY ENERGY, INC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2016-01-01 DEBBIE MARTIN 2018-12-05
502 2016-01-01 ROLANDO VAZQUEZ 2022-10-03

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2016-01-01			DEBBIE MARTIN	2018-12-05
502	2016-01-01	ROLANDO VAZQUEZ	2022-10-03

Plan Statistics for CURTIS BAY ENERGY, INC

401k plan membership statisitcs for CURTIS BAY ENERGY, INC

Measure Date Value
2016: CURTIS BAY ENERGY, INC 2016 401k membership
Total participants, beginning-of-year 2016-01-01 127
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 145
Total of all active and inactive participants 2016-01-01 145
Total participants 2016-01-01 145
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Number of employers contributing to the scheme 2016-01-01 0

Measure	Date	Value
2016: CURTIS BAY ENERGY, INC 2016 401k membership
Total participants, beginning-of-year	2016-01-01	127
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	145
Total of all active and inactive participants	2016-01-01	145
Total participants	2016-01-01	145
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Number of employers contributing to the scheme	2016-01-01	0

Form 5500 Responses for CURTIS BAY ENERGY, INC

2016: CURTIS BAY ENERGY, INC 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )

Policy contract number

1TLD

Policy instance

Insurance contract or identification number	1TLD
Number of Individuals Covered	124
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $44,750
Total amount of fees paid to insurance company	USD $6,959
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,278,608
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $44,750
Amount paid for insurance broker fees	6959
Additional information about fees paid to insurance broker	MEDICAL CONTRACTS X PCPM, NON-MONETARY INCENTIVE
Insurance broker organization code?	3

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

Policy contract number

474412

Policy instance

Insurance contract or identification number	474412
Number of Individuals Covered	114
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $2,984
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $2,984
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000AW7Z

Policy instance

Insurance contract or identification number	G000AW7Z
Number of Individuals Covered	145
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $9,406
Total amount of fees paid to insurance company	USD $4,676
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
Welfare Benefit Premiums Paid to Carrier	USD $91,975
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,406
Amount paid for insurance broker fees	1917
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

Potentially related plans

CURTIS BAY ENERGY, INC. 401(K) RETIREMENT PLAN [EIN = 521592703]

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Company Name:	CURTIS BAY ENERGY, INC.
Employer identification number (EIN):	521770031
NAIC Classification:	562000