401k Plan data: MOSS SUPPLY COMPANY EMPLOYEE BENEFITS PLAN plan

MOSS SUPPLY COMPANY EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	MOSS SUPPLY COMPANY EMPLOYEE BENEFITS PLAN
Plan identification number	501

MOSS SUPPLY COMPANY EMPLOYEE BENEFITS 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 Other welfare benefit cover

401k Sponsoring company profile

MOSS SUPPLY COMPANY has sponsored the creation of one or more 401k plans.

Company Name: MOSS SUPPLY COMPANY

Employer identification number (EIN): 560746821

NAIC Classification: 339900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MOSS SUPPLY COMPANY EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-11-01

Plan Statistics for MOSS SUPPLY COMPANY EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for MOSS SUPPLY COMPANY EMPLOYEE BENEFITS PLAN

Measure Date Value
2020: MOSS SUPPLY COMPANY EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year 2020-11-01 230
Total number of active participants reported on line 7a of the Form 5500 2020-11-01 230
Number of retired or separated participants receiving benefits 2020-11-01 0
Number of other retired or separated participants entitled to future benefits 2020-11-01 0
Total of all active and inactive participants 2020-11-01 230

Measure	Date	Value
2020: MOSS SUPPLY COMPANY EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year	2020-11-01	230
Total number of active participants reported on line 7a of the Form 5500	2020-11-01	230
Number of retired or separated participants receiving benefits	2020-11-01	0
Number of other retired or separated participants entitled to future benefits	2020-11-01	0
Total of all active and inactive participants	2020-11-01	230

Form 5500 Responses for MOSS SUPPLY COMPANY EMPLOYEE BENEFITS PLAN

2020: MOSS SUPPLY COMPANY EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-11-01	Type of plan entity	Single employer plan
2020-11-01	Submission has been amended	No
2020-11-01	This submission is the final filing	No
2020-11-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-11-01	Plan is a collectively bargained plan	No
2020-11-01	Plan funding arrangement – Insurance	Yes
2020-11-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-11-01	Plan benefit arrangement – Insurance	Yes
2020-11-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

AMERICAN UNITED LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60895 )

Policy contract number

G 00620442

Policy instance

Insurance contract or identification number	G 00620442
Number of Individuals Covered	104
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $17,058
Total amount of fees paid to insurance company	USD $2,700
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE, DEPENDENT LIFE, VOLUNTARY AD&D, DEPENDENT 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 $111,672
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $17,058
Amount paid for insurance broker fees	2700
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

38905

Policy instance

Insurance contract or identification number	38905
Number of Individuals Covered	77
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $4,688
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, CANCER, 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 $34,591
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,784
Insurance broker organization code?	3

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

830697

Policy instance

Insurance contract or identification number	830697
Number of Individuals Covered	102
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $3,629
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE, DEPENDENT LIFE, VOLUNTARY AD&D, DEPENDENT 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 $46,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,573
Insurance broker organization code?	3

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

14158994-1001

Policy instance

Insurance contract or identification number	14158994-1001
Number of Individuals Covered	8
Insurance policy start date	2020-11-01
Insurance policy end date	2021-10-31
Total amount of commissions paid to insurance broker	USD $3,104
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
Other welfare benefits provided	WELLNESS
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 $106,077
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,792
Insurance broker organization code?	3

Potentially related plans

MOSS SUPPLY COMPANY EMPLOYEE BENEFITS PLAN [EIN = 271316203]

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Company Name:	MOSS SUPPLY COMPANY
Employer identification number (EIN):	560746821
NAIC Classification:	339900