401k Plan data: JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN plan

JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN 401k Plan overview

Plan Name	JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN
Plan identification number	503

JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Temporary disability (accident and sickness) Other welfare benefit cover

401k Sponsoring company profile

JERNIGAN OIL COMPANY, INC. has sponsored the creation of one or more 401k plans.

Company Name: JERNIGAN OIL COMPANY, INC.

Employer identification number (EIN): 560795696

NAIC Classification: 211120
NAIC Description: Crude Petroleum Extraction

Form 5500 Filing Information

Submission information for form 5500 for 401k plan JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2015-06-01 MICHELLE SAWYER
503 2014-06-01 MICHELLE SAWYER

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
503	2015-06-01	MICHELLE SAWYER
503	2014-06-01	MICHELLE SAWYER

Plan Statistics for JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN

401k plan membership statisitcs for JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN

Measure Date Value
2015: JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-06-01 100
Total number of active participants reported on line 7a of the Form 5500 2015-06-01 0
Number of retired or separated participants receiving benefits 2015-06-01 0
Number of other retired or separated participants entitled to future benefits 2015-06-01 0
Total of all active and inactive participants 2015-06-01 0
2014: JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-06-01 100
Total number of active participants reported on line 7a of the Form 5500 2014-06-01 100
Number of retired or separated participants receiving benefits 2014-06-01 0
Number of other retired or separated participants entitled to future benefits 2014-06-01 0
Total of all active and inactive participants 2014-06-01 100

Measure	Date	Value
2015: JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-06-01	100
Total number of active participants reported on line 7a of the Form 5500	2015-06-01	0
Number of retired or separated participants receiving benefits	2015-06-01	0
Number of other retired or separated participants entitled to future benefits	2015-06-01	0
Total of all active and inactive participants	2015-06-01	0
2014: JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-06-01	100
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	100
Number of retired or separated participants receiving benefits	2014-06-01	0
Number of other retired or separated participants entitled to future benefits	2014-06-01	0
Total of all active and inactive participants	2014-06-01	100

Form 5500 Responses for JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN

2015: JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN 2015 form 5500 responses
2015-06-01	Type of plan entity	Single employer plan
2015-06-01	Submission has been amended	No
2015-06-01	This submission is the final filing	Yes
2015-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-06-01	Plan is a collectively bargained plan	No
2015-06-01	Plan funding arrangement – Insurance	Yes
2015-06-01	Plan benefit arrangement – Insurance	Yes
2014: JERNIGAN OIL COMPANY, INC. ANCILLARY BENEFIT PLAN 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	First time form 5500 has been submitted	Yes
2014-06-01	Submission has been amended	No
2014-06-01	This submission is the final filing	No
2014-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-06-01	Plan is a collectively bargained plan	No
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

28969

Policy instance

Insurance contract or identification number	28969
Number of Individuals Covered	292
Insurance policy start date	2015-06-01
Insurance policy end date	2016-05-31
Total amount of commissions paid to insurance broker	USD $41,636
Total amount of fees paid to insurance company	USD $2,894
Are there contracts with allocated funds for individual policies?	No
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	HOSPITAL, ACCIDENT, CANCER
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 $200,904
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,651
Amount paid for insurance broker fees	871
Additional information about fees paid to insurance broker	ADDITIONAL BROKER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	KIM WILLIAMS

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

28969

Policy instance

Insurance contract or identification number	28969
Number of Individuals Covered	320
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $56,309
Total amount of fees paid to insurance company	USD $2,119
Are there contracts with allocated funds for individual policies?	No
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	HOSPITAL, ACCIDENT, CANCER
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 $200,098
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $19,286
Amount paid for insurance broker fees	802
Additional information about fees paid to insurance broker	ADDITIONAL BROKER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	COREY D QUATTLEBAUM

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Company Name:	JERNIGAN OIL COMPANY, INC.
Employer identification number (EIN):	560795696
NAIC Classification:	211120
NAIC Description:	Crude Petroleum Extraction