401k Plan data: CAFRITZ INTERESTS WELFARE BENEFIT PLAN plan

CAFRITZ INTERESTS WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	CAFRITZ INTERESTS WELFARE BENEFIT PLAN
Plan identification number	508

CAFRITZ INTERESTS WELFARE BENEFIT 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) Prepaid legal Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

POTOMAC HOSPITALITY SERVICES has sponsored the creation of one or more 401k plans.

Company Name: POTOMAC HOSPITALITY SERVICES

Employer identification number (EIN): 521851615

NAIC Classification: 721110
NAIC Description: Hotels (except Casino Hotels) and Motels

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CAFRITZ INTERESTS WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
508 2020-01-01 ADAM GOLLANCE 2021-07-18

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
508	2020-01-01	ADAM GOLLANCE	2021-07-18

Plan Statistics for CAFRITZ INTERESTS WELFARE BENEFIT PLAN

401k plan membership statisitcs for CAFRITZ INTERESTS WELFARE BENEFIT PLAN

Measure Date Value
2020: CAFRITZ INTERESTS WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 197
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 64
Number of retired or separated participants receiving benefits 2020-01-01 6
Number of other retired or separated participants entitled to future benefits 2020-01-01 167
Total of all active and inactive participants 2020-01-01 237

Measure	Date	Value
2020: CAFRITZ INTERESTS WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	197
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	64
Number of retired or separated participants receiving benefits	2020-01-01	6
Number of other retired or separated participants entitled to future benefits	2020-01-01	167
Total of all active and inactive participants	2020-01-01	237

Form 5500 Responses for CAFRITZ INTERESTS WELFARE BENEFIT PLAN

2020: CAFRITZ INTERESTS WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
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 funding arrangement – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLANS OF MID-ATLANTIC (National Association of Insurance Commissioners NAIC id number: 95639 )

Policy contract number

20011

Policy instance

Insurance contract or identification number	20011
Number of Individuals Covered	162
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $60,999
Total amount of fees paid to insurance company	USD $8,540
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 $1,108,914
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $36,614
Amount paid for insurance broker fees	8540
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

ER00028221

Policy instance

Insurance contract or identification number	ER00028221
Number of Individuals Covered	40
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,546
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	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 $14,986
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,273
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

CONTINENTAL AMERICAN INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71730 )

Policy contract number

22840

Policy instance

Insurance contract or identification number	22840
Number of Individuals Covered	121
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,691
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	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	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 $11,320
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,691
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

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

Policy contract number

12029-128

Policy instance

Insurance contract or identification number	12029-128
Number of Individuals Covered	38
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $185
Total amount of fees paid to insurance company	USD $578
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $185
Amount paid for insurance broker fees	578
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

04S3900

Policy instance

Insurance contract or identification number	04S3900
Number of Individuals Covered	7
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $4,270
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 $73,774
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,270
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10104728 00000

Policy instance

Insurance contract or identification number	10104728 00000
Number of Individuals Covered	21
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $2,380
Total amount of fees paid to insurance company	USD $81
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	Yes
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 $15,865
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,380
Amount paid for insurance broker fees	81
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10104727 00000

Policy instance

Insurance contract or identification number	10104727 00000
Number of Individuals Covered	60
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,692
Total amount of fees paid to insurance company	USD $126
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	AD&D
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 $18,626
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,692
Amount paid for insurance broker fees	126
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

DOMINIONNATIONAL DENTAL (National Association of Insurance Commissioners NAIC id number: 95657 )

Policy contract number

37300

Policy instance

Insurance contract or identification number	37300
Number of Individuals Covered	64
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,565
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	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 $36,571
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,565
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10104729 00000

Policy instance

Insurance contract or identification number	10104729 00000
Number of Individuals Covered	64
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,126
Total amount of fees paid to insurance company	USD $120
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	Yes
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 $12,432
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,126
Amount paid for insurance broker fees	120
Additional information about fees paid to insurance broker	COMMISSIONS AND FEES
Insurance broker organization code?	3

PRE-PAID LEGAL SERVICES DBA LEGAL SHIELD (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

16756

Policy instance

Insurance contract or identification number	16756
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $172
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	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	LEGAL
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 $640
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $87
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3

Potentially related plans

CAFRITZ INTERESTS LLC 401(K) PLAN [EIN = 203843827]

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Company Name:	POTOMAC HOSPITALITY SERVICES
Employer identification number (EIN):	521851615
NAIC Classification:	721110
NAIC Description:	Hotels (except Casino Hotels) and Motels