401k Plan data: ARRY'S ROOFING SERVICES, INC. ANCILLARY BENEFITS PLAN plan

ARRY'S ROOFING SERVICES, INC. ANCILLARY BENEFITS PLAN 401k Plan overview

Plan Name	ARRY'S ROOFING SERVICES, INC. ANCILLARY BENEFITS PLAN
Plan identification number	502

ARRY'S ROOFING SERVICES, INC. ANCILLARY BENEFITS PLAN Benefits

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

401k Sponsoring company profile

ARRYS ROOFING SERVICES, INC. has sponsored the creation of one or more 401k plans.

Company Name: ARRYS ROOFING SERVICES, INC.

Employer identification number (EIN): 593014507

NAIC Classification: 238100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ARRY'S ROOFING SERVICES, INC. ANCILLARY BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2019-10-01

Plan Statistics for ARRY'S ROOFING SERVICES, INC. ANCILLARY BENEFITS PLAN

401k plan membership statisitcs for ARRY'S ROOFING SERVICES, INC. ANCILLARY BENEFITS PLAN

Measure Date Value
2019: ARRY'S ROOFING SERVICES, INC. ANCILLARY BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year 2019-10-01 104
Total number of active participants reported on line 7a of the Form 5500 2019-10-01 0
Number of retired or separated participants receiving benefits 2019-10-01 0
Number of other retired or separated participants entitled to future benefits 2019-10-01 0
Total of all active and inactive participants 2019-10-01 0

Measure	Date	Value
2019: ARRY'S ROOFING SERVICES, INC. ANCILLARY BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year	2019-10-01	104
Total number of active participants reported on line 7a of the Form 5500	2019-10-01	0
Number of retired or separated participants receiving benefits	2019-10-01	0
Number of other retired or separated participants entitled to future benefits	2019-10-01	0
Total of all active and inactive participants	2019-10-01	0

Form 5500 Responses for ARRY'S ROOFING SERVICES, INC. ANCILLARY BENEFITS PLAN

2019: ARRY'S ROOFING SERVICES, INC. ANCILLARY BENEFITS PLAN 2019 form 5500 responses
2019-10-01	Type of plan entity	Single employer plan
2019-10-01	First time form 5500 has been submitted	Yes
2019-10-01	Submission has been amended	No
2019-10-01	This submission is the final filing	Yes
2019-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-10-01	Plan is a collectively bargained plan	No
2019-10-01	Plan funding arrangement – Insurance	Yes
2019-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00565447

Policy instance

Insurance contract or identification number	00565447
Number of Individuals Covered	104
Insurance policy start date	2019-10-01
Insurance policy end date	2020-09-30
Total amount of commissions paid to insurance broker	USD $6,003
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CANCER,VOLUNTARY CRITICAL ILLNESS, VOLUNTARY HOSPITAL INDEMNITY
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 $57,096
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,003
Insurance broker organization code?	3

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Company Name:	ARRYS ROOFING SERVICES, INC.
Employer identification number (EIN):	593014507
NAIC Classification:	238100