401k Plan data: ATLANTIC PACIFIC EQUIPMENT, INC. HEALTH AND WELFARE PLAN plan

ATLANTIC PACIFIC EQUIPMENT, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	ATLANTIC PACIFIC EQUIPMENT, INC. HEALTH AND WELFARE PLAN
Plan identification number	501

ATLANTIC PACIFIC EQUIPMENT, INC. HEALTH AND 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) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

ATLANTIC PACIFIC EQUIPMENT, INC. DBA AT-PAC, INC. has sponsored the creation of one or more 401k plans.

Company Name: ATLANTIC PACIFIC EQUIPMENT, INC. DBA AT-PAC, INC.

Employer identification number (EIN): 582013827

NAIC Classification: 238290
NAIC Description: Other Building Equipment Contractors

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ATLANTIC PACIFIC EQUIPMENT, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2018-06-01 HARLEY KARSEBOOM 2020-02-19
501 2018-06-01 HARLEY C. KAREEBOOM 2020-10-07

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2018-06-01	HARLEY KARSEBOOM	2020-02-19
501	2018-06-01	HARLEY C. KAREEBOOM	2020-10-07

Plan Statistics for ATLANTIC PACIFIC EQUIPMENT, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for ATLANTIC PACIFIC EQUIPMENT, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2018: ATLANTIC PACIFIC EQUIPMENT, INC. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-06-01 104
Total number of active participants reported on line 7a of the Form 5500 2018-06-01 119
Number of retired or separated participants receiving benefits 2018-06-01 0
Number of other retired or separated participants entitled to future benefits 2018-06-01 0
Total of all active and inactive participants 2018-06-01 119
Number of employers contributing to the scheme 2018-06-01 0

Measure	Date	Value
2018: ATLANTIC PACIFIC EQUIPMENT, INC. HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-06-01	104
Total number of active participants reported on line 7a of the Form 5500	2018-06-01	119
Number of retired or separated participants receiving benefits	2018-06-01	0
Number of other retired or separated participants entitled to future benefits	2018-06-01	0
Total of all active and inactive participants	2018-06-01	119
Number of employers contributing to the scheme	2018-06-01	0

Form 5500 Responses for ATLANTIC PACIFIC EQUIPMENT, INC. HEALTH AND WELFARE PLAN

2018: ATLANTIC PACIFIC EQUIPMENT, INC. HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-06-01	Type of plan entity	Single employer plan
2018-06-01	First time form 5500 has been submitted	Yes
2018-06-01	Submission has been amended	Yes
2018-06-01	Plan funding arrangement – Insurance	Yes
2018-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

609201

Policy instance

Insurance contract or identification number	609201
Number of Individuals Covered	154
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $34,756
Total amount of fees paid to insurance company	USD $1,605
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $570,803
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $34,756
Amount paid for insurance broker fees	1605
Additional information about fees paid to insurance broker	INCENTIVE COMPENSATION
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

159879

Policy instance

Insurance contract or identification number	159879
Number of Individuals Covered	102
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $1,927
Total amount of fees paid to insurance company	USD $597
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,927
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	CONTINGENT COMPENSATION

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 32395 )

Policy contract number

30040740

Policy instance

Insurance contract or identification number	30040740
Number of Individuals Covered	109
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $955
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $15,335
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $955
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

10243020

Policy instance

Insurance contract or identification number	10243020
Number of Individuals Covered	99
Insurance policy start date	2018-06-01
Insurance policy end date	2019-05-31
Total amount of commissions paid to insurance broker	USD $7,009
Total amount of fees paid to insurance company	USD $0
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	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $46,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,009
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	ATLANTIC PACIFIC EQUIPMENT, INC. DBA AT-PAC, INC.
Employer identification number (EIN):	582013827
NAIC Classification:	238290
NAIC Description:	Other Building Equipment Contractors