401k Plan data: HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN plan

HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN
Plan identification number	501

HOLLY MTN. ENTERPRISES, INC. 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) Other welfare benefit cover

401k Sponsoring company profile

HOLLY MTN. ENTERPRISES, INC. has sponsored the creation of one or more 401k plans.

Company Name: HOLLY MTN. ENTERPRISES, INC.

Employer identification number (EIN): 561770163

NAIC Classification: 445120
NAIC Description: Convenience Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-05-01 SIERRA GUENTHER
501 2015-05-01 SUSAN DUDEK
501 2014-05-01 SUSAN DUDEK

Plan id#	Filing Submission Date	Name of Administrator
501	2016-05-01	SIERRA GUENTHER
501	2015-05-01	SUSAN DUDEK
501	2014-05-01	SUSAN DUDEK

Plan Statistics for HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN

Measure Date Value
2016: HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-05-01 115
Total number of active participants reported on line 7a of the Form 5500 2016-05-01 128
Number of retired or separated participants receiving benefits 2016-05-01 1
Number of other retired or separated participants entitled to future benefits 2016-05-01 4
Total of all active and inactive participants 2016-05-01 133
2015: HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-05-01 111
Total number of active participants reported on line 7a of the Form 5500 2015-05-01 123
Number of retired or separated participants receiving benefits 2015-05-01 1
Number of other retired or separated participants entitled to future benefits 2015-05-01 4
Total of all active and inactive participants 2015-05-01 128
2014: HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-05-01 113
Total number of active participants reported on line 7a of the Form 5500 2014-05-01 103
Number of retired or separated participants receiving benefits 2014-05-01 0
Number of other retired or separated participants entitled to future benefits 2014-05-01 0
Total of all active and inactive participants 2014-05-01 103

Measure	Date	Value
2016: HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-05-01	115
Total number of active participants reported on line 7a of the Form 5500	2016-05-01	128
Number of retired or separated participants receiving benefits	2016-05-01	1
Number of other retired or separated participants entitled to future benefits	2016-05-01	4
Total of all active and inactive participants	2016-05-01	133
2015: HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-05-01	111
Total number of active participants reported on line 7a of the Form 5500	2015-05-01	123
Number of retired or separated participants receiving benefits	2015-05-01	1
Number of other retired or separated participants entitled to future benefits	2015-05-01	4
Total of all active and inactive participants	2015-05-01	128
2014: HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-05-01	113
Total number of active participants reported on line 7a of the Form 5500	2014-05-01	103
Number of retired or separated participants receiving benefits	2014-05-01	0
Number of other retired or separated participants entitled to future benefits	2014-05-01	0
Total of all active and inactive participants	2014-05-01	103

Form 5500 Responses for HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN

2016: HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-05-01	Type of plan entity	Single employer plan
2016-05-01	Submission has been amended	No
2016-05-01	This submission is the final filing	No
2016-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-05-01	Plan is a collectively bargained plan	No
2016-05-01	Plan funding arrangement – Insurance	Yes
2016-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-05-01	Plan benefit arrangement – Insurance	Yes
2016-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-05-01	Type of plan entity	Single employer plan
2015-05-01	Submission has been amended	No
2015-05-01	This submission is the final filing	No
2015-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-05-01	Plan is a collectively bargained plan	No
2015-05-01	Plan funding arrangement – Insurance	Yes
2015-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-05-01	Plan benefit arrangement – Insurance	Yes
2015-05-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: HOLLY MTN. ENTERPRISES, INC. EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-05-01	Type of plan entity	Single employer plan
2014-05-01	First time form 5500 has been submitted	Yes
2014-05-01	Submission has been amended	No
2014-05-01	This submission is the final filing	No
2014-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-05-01	Plan is a collectively bargained plan	No
2014-05-01	Plan funding arrangement – Insurance	Yes
2014-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-05-01	Plan benefit arrangement – Insurance	Yes
2014-05-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3488202

Policy instance

Insurance contract or identification number	E3488202
Number of Individuals Covered	17
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $1,715
Total amount of fees paid to insurance company	USD $179
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	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPPLEMENTAL & DEPENDENT LIFE, SUPPLEMENTAL & DEPENDENT AD&D, ACCIDENT, CANCER, UNIVERSAL LIFE
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 $11,949
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $935
Amount paid for insurance broker fees	133
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	INSYNC BENEFITS INC

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM605167

Policy instance

Insurance contract or identification number	SGM605167
Number of Individuals Covered	123
Insurance policy start date	2015-05-01
Insurance policy end date	2016-04-30
Total amount of commissions paid to insurance broker	USD $1,456
Total amount of fees paid to insurance company	USD $0
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
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 $9,705
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,456
Insurance broker organization code?	3
Insurance broker name	CHARLES STEWART FORESTER

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E3488202

Policy instance

Insurance contract or identification number	E3488202
Number of Individuals Covered	20
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $1,477
Total amount of fees paid to insurance company	USD $58
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	No
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	SUPP & DEP LIFE, SUPP & DEP AD&D, ACCIDENT, CANCER, UNIVERSAL LIFE
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 $10,782
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $751
Insurance broker organization code?	3
Amount paid for insurance broker fees	35
Additional information about fees paid to insurance broker	FEES
Insurance broker name	INSYNC BENEFITS INC

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

Policy contract number

75709

Policy instance

Insurance contract or identification number	75709
Number of Individuals Covered	20
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $836
Total amount of fees paid to insurance company	USD $0
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	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	INDIVIDUAL ACCIDENT, CANCER, DISABILITY AND UNIVERSAL LIFE
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 $7,263
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $392
Insurance broker organization code?	3
Insurance broker name	EAR F WESTBROOK SR

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM605167

Policy instance

Insurance contract or identification number	SGM605167
Number of Individuals Covered	103
Insurance policy start date	2014-05-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $1,257
Total amount of fees paid to insurance company	USD $0
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	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 $9,153
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,257
Insurance broker organization code?	3
Insurance broker name	CHARLES STEWART FORESTER

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Company Name:	HOLLY MTN. ENTERPRISES, INC.
Employer identification number (EIN):	561770163
NAIC Classification:	445120
NAIC Description:	Convenience Stores