401k Plan data: ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN plan

ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN 401k Plan overview

Plan Name	ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN
Plan identification number	502

ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Dental Vision 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

ORIGEN BIOMEDICAL, INC. has sponsored the creation of one or more 401k plans.

Company Name: ORIGEN BIOMEDICAL, INC.

Employer identification number (EIN): 521824990

NAIC Classification: 339110

Additional information about ORIGEN BIOMEDICAL, INC.

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 1990-07-27

Company Identification Number: 0116075300

Legal Registered Office Address: 7000 BURLESON RD STE D

AUSTIN
United States of America (USA)
78744

More information about ORIGEN BIOMEDICAL, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2021-01-01
502 2021-01-01 GREG SANSOM 2023-07-24
502 2020-01-01 GREG SANSOM 2021-09-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
502	2021-01-01
502	2021-01-01	GREG SANSOM	2023-07-24
502	2020-01-01	GREG SANSOM	2021-09-01

Plan Statistics for ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN

401k plan membership statisitcs for ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN

Measure Date Value
2021: ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 144
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 110
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 110
2020: ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 107
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 138
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 138

Measure	Date	Value
2021: ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	144
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	110
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	110
2020: ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	107
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	138
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	138

Form 5500 Responses for ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN

2021: ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: ORIGEN BIOMEDICAL, INC. ANCILLARY BENEFITS PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	First time form 5500 has been submitted	Yes
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1087365

Policy instance

Insurance contract or identification number	1087365
Number of Individuals Covered	172
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $16,414
Total amount of fees paid to insurance company	USD $2,957
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	ACCIDENTAL DEATH & DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS
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 $145,641
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,414
Amount paid for insurance broker fees	2273
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1087365

Policy instance

Insurance contract or identification number	1087365
Number of Individuals Covered	216
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $14,702
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	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	ACCIDENTAL DEATH & DISMEMBERMENT, EMPLOYEE ASSISTANCE PROGRAM, ACCIDENT, CRITICAL ILLNESS
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 $138,289
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $14,702
Insurance broker organization code?	3

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Company Name:	ORIGEN BIOMEDICAL, INC.
Employer identification number (EIN):	521824990
NAIC Classification:	339110

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	1990-07-27
Company Identification Number:	0116075300
Legal Registered Office Address:	7000 BURLESON RD STE D AUSTIN United States of America (USA) 78744