401k Plan data: MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN plan

MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN 401k Plan overview

Plan Name	MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN
Plan identification number	501

MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE 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

MARINER SANDS COUNTRY CLUB, INC. has sponsored the creation of one or more 401k plans.

Company Name: MARINER SANDS COUNTRY CLUB, INC.

Employer identification number (EIN): 592147192

NAIC Classification: 531310

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-05-01
501 2009-07-01 ADRAINE CHAPMAN

Plan Statistics for MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN

401k plan membership statisitcs for MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN

Measure Date Value
2022: MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-05-01 82
Total number of active participants reported on line 7a of the Form 5500 2022-05-01 141
Total of all active and inactive participants 2022-05-01 141
2009: MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN 2009 401k membership
Total participants, beginning-of-year 2009-07-01 98
Total number of active participants reported on line 7a of the Form 5500 2009-07-01 114
Total of all active and inactive participants 2009-07-01 114

Measure	Date	Value
2022: MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-05-01	82
Total number of active participants reported on line 7a of the Form 5500	2022-05-01	141
Total of all active and inactive participants	2022-05-01	141
2009: MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN 2009 401k membership
Total participants, beginning-of-year	2009-07-01	98
Total number of active participants reported on line 7a of the Form 5500	2009-07-01	114
Total of all active and inactive participants	2009-07-01	114

Form 5500 Responses for MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN

2022: MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN 2022 form 5500 responses
2022-05-01	Type of plan entity	Single employer plan
2022-05-01	Submission has been amended	No
2022-05-01	This submission is the final filing	No
2022-05-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-05-01	Plan is a collectively bargained plan	No
2022-05-01	Plan funding arrangement – Insurance	Yes
2022-05-01	Plan benefit arrangement – Insurance	Yes
2009: MARINER SANDS COUNTRY CLUB EMPLOYEE HEALTH CARE PLAN 2009 form 5500 responses
2009-07-01	Type of plan entity	Single employer plan
2009-07-01	Submission has been amended	No
2009-07-01	This submission is the final filing	No
2009-07-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2009-07-01	Plan is a collectively bargained plan	No
2009-07-01	Plan funding arrangement – Insurance	Yes
2009-07-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000BJLZ

Policy instance

Insurance contract or identification number	G000BJLZ
Number of Individuals Covered	119
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $7,712
Total amount of fees paid to insurance company	USD $5,009
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	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	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 $51,444
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,712
Amount paid for insurance broker fees	3119
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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

Policy contract number

BB985

Policy instance

Insurance contract or identification number	BB985
Number of Individuals Covered	15
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $1,038
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
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 $6,835
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $774
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

037903

Policy instance

Insurance contract or identification number	037903
Number of Individuals Covered	130
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $697
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	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
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 $7,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $533
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0175808

Policy instance

Insurance contract or identification number	0175808
Number of Individuals Covered	141
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $5,476
Total amount of fees paid to insurance company	USD $6,442
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	Yes
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
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 $1,057,186
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,476
Amount paid for insurance broker fees	6442
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

Potentially related plans

MARINER SANDS COUNTRY CLUB 401K RETIREMENT PLAN [EIN = 592054922]

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Company Name:	MARINER SANDS COUNTRY CLUB, INC.
Employer identification number (EIN):	592147192
NAIC Classification:	531310