401k Plan data: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN plan

DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN
Plan identification number	501

DELEK US HOLDINGS AND SUBSIDIARIES 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) Other welfare benefit cover

401k Sponsoring company profile

DELEK US HOLDINGS, INC. has sponsored the creation of one or more 401k plans.

Company Name: DELEK US HOLDINGS, INC.

Employer identification number (EIN): 522319066

NAIC Classification: 447100
NAIC Description: Gasoline Stations, Gas

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-01-01 JARED SERFF JARED SERFF 2017-07-31
501 2015-01-01 DONALD HOLMES
501 2014-01-01 SIDNEY WILLIAMS
501 2013-01-01 RANDY SWINEHART
501 2013-01-01 AMANDA DAVIS
501 2012-01-01 RANDY SWINEHART KENT THOMAS 2013-10-15
501 2011-01-01 RANDY SWINEHART
501 2010-01-01 RANDY SWINEHART KENT THOMAS 2011-07-28
501 2009-01-01 RANDY SWINEHART KENT THOMAS 2010-06-28

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2016-01-01	JARED SERFF	JARED SERFF	2017-07-31
501	2015-01-01	DONALD HOLMES
501	2014-01-01	SIDNEY WILLIAMS
501	2013-01-01	RANDY SWINEHART
501	2013-01-01	AMANDA DAVIS
501	2012-01-01	RANDY SWINEHART	KENT THOMAS	2013-10-15
501	2011-01-01	RANDY SWINEHART
501	2010-01-01	RANDY SWINEHART	KENT THOMAS	2011-07-28
501	2009-01-01	RANDY SWINEHART	KENT THOMAS	2010-06-28

Plan Statistics for DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN

401k plan membership statisitcs for DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN

Measure Date Value
2016: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 1,664
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 1,158
Number of retired or separated participants receiving benefits 2016-01-01 16
Number of other retired or separated participants entitled to future benefits 2016-01-01 8
Total of all active and inactive participants 2016-01-01 1,182
2015: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 1,771
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 1,725
Number of retired or separated participants receiving benefits 2015-01-01 27
Number of other retired or separated participants entitled to future benefits 2015-01-01 38
Total of all active and inactive participants 2015-01-01 1,790
2014: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 1,546
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 1,771
Number of retired or separated participants receiving benefits 2014-01-01 4
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 1,775
2013: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 1,395
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 1,546
Number of retired or separated participants receiving benefits 2013-01-01 30
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 1,576
2012: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 855
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 1,398
Number of retired or separated participants receiving benefits 2012-01-01 8
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 1,406
2011: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 869
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 841
Number of retired or separated participants receiving benefits 2011-01-01 14
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 855
2010: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 849
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 845
Number of retired or separated participants receiving benefits 2010-01-01 24
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 869
2009: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 885
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 839
Number of retired or separated participants receiving benefits 2009-01-01 10
Total of all active and inactive participants 2009-01-01 849
Total participants 2009-01-01 849

Measure	Date	Value
2016: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	1,664
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	1,158
Number of retired or separated participants receiving benefits	2016-01-01	16
Number of other retired or separated participants entitled to future benefits	2016-01-01	8
Total of all active and inactive participants	2016-01-01	1,182
2015: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	1,771
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	1,725
Number of retired or separated participants receiving benefits	2015-01-01	27
Number of other retired or separated participants entitled to future benefits	2015-01-01	38
Total of all active and inactive participants	2015-01-01	1,790
2014: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	1,546
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	1,771
Number of retired or separated participants receiving benefits	2014-01-01	4
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	1,775
2013: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	1,395
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	1,546
Number of retired or separated participants receiving benefits	2013-01-01	30
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	1,576
2012: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	855
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	1,398
Number of retired or separated participants receiving benefits	2012-01-01	8
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	1,406
2011: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	869
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	841
Number of retired or separated participants receiving benefits	2011-01-01	14
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	855
2010: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	849
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	845
Number of retired or separated participants receiving benefits	2010-01-01	24
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	869
2009: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	885
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	839
Number of retired or separated participants receiving benefits	2009-01-01	10
Total of all active and inactive participants	2009-01-01	849
Total participants	2009-01-01	849

Form 5500 Responses for DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN

2016: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 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 funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2010: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: DELEK US HOLDINGS AND SUBSIDIARIES HEALTH & WELFARE PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )
Policy contract number	1663
Policy instance	4
HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )
Policy contract number	3690
Policy instance	3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10197134*
Policy instance	5
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	1179
Policy instance	7
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0065458
Policy instance	8
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number	130406, 129066
Policy instance	1
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0006999400
Policy instance	6
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000099062747*
Policy instance	2
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0065458
Policy instance	4
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL149156*
Policy instance	2
DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )
Policy contract number	1663
Policy instance	5
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000099062747*
Policy instance	1
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0006999400
Policy instance	6
SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )
Policy contract number	1179
Policy instance	7
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3335220
Policy instance	3
DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )
Policy contract number	1663
Policy instance	2
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3335220
Policy instance	7
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0006999400
Policy instance	3
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0065458
Policy instance	4
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	ST-0100-2016
Policy instance	5
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL149156*
Policy instance	6
PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68195 )
Policy contract number	0006999400
Policy instance	7
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000099062747*
Policy instance	1
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	ST-0100-2016
Policy instance	2
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL149156*
Policy instance	3
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3335220
Policy instance	4
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0065458
Policy instance	5
DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )
Policy contract number	1663
Policy instance	6
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	ST-0100-2016
Policy instance	2
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL149156*
Policy instance	3
BLUECROSS BLUESHIELD OF TENNESSEE, INC. (National Association of Insurance Commissioners NAIC id number: 54518 )
Policy contract number	125177
Policy instance	5
UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )
Policy contract number	R0065458
Policy instance	6
CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )
Policy contract number	3335220
Policy instance	4
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000099062747*
Policy instance	1
DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )
Policy contract number	1663
Policy instance	7
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000099062747*
Policy instance	1
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK750610*
Policy instance	2
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	ST-0100-2016
Policy instance	3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	730567
Policy instance	4
FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )
Policy contract number	000099062747*
Policy instance	1
LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )
Policy contract number	LK750610*
Policy instance	2
CONNECTICUT GENERAL LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 62308 )
Policy contract number	ST-0100-2016
Policy instance	3
DELTA DENTAL OF TENNESSEE (National Association of Insurance Commissioners NAIC id number: 54526 )
Policy contract number	1663
Policy instance	4

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Company Name:	DELEK US HOLDINGS, INC.
Employer identification number (EIN):	522319066
NAIC Classification:	447100
NAIC Description:	Gasoline Stations, Gas