401k Plan data: YUSHIRO/QUALICHEM EMPLOYEE BENEFIT PLAN plan

YUSHIRO/QUALICHEM EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	YUSHIRO/QUALICHEM EMPLOYEE BENEFIT PLAN
Plan identification number	501

YUSHIRO/QUALICHEM EMPLOYEE BENEFIT 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 Other welfare benefit cover

401k Sponsoring company profile

YUSHIRO MANUFACTURING AMERICA, INC. has sponsored the creation of one or more 401k plans.

Company Name: YUSHIRO MANUFACTURING AMERICA, INC.

Employer identification number (EIN): 621296001

NAIC Classification: 326100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan YUSHIRO/QUALICHEM EMPLOYEE BENEFIT PLAN

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

Plan Statistics for YUSHIRO/QUALICHEM EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for YUSHIRO/QUALICHEM EMPLOYEE BENEFIT PLAN

Measure Date Value
2022: YUSHIRO/QUALICHEM EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-05-01 136
Total number of active participants reported on line 7a of the Form 5500 2022-05-01 133
Total of all active and inactive participants 2022-05-01 133
Total participants 2022-05-01 133

Measure	Date	Value
2022: YUSHIRO/QUALICHEM EMPLOYEE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-05-01	136
Total number of active participants reported on line 7a of the Form 5500	2022-05-01	133
Total of all active and inactive participants	2022-05-01	133
Total participants	2022-05-01	133

Form 5500 Responses for YUSHIRO/QUALICHEM EMPLOYEE BENEFIT PLAN

2022: YUSHIRO/QUALICHEM EMPLOYEE BENEFIT PLAN 2022 form 5500 responses
2022-05-01	Type of plan entity	Single employer plan
2022-05-01	First time form 5500 has been submitted	Yes
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

Insurance Providers Used on plan

DELTA DENTAL OF VIRGINIA (National Association of Insurance Commissioners NAIC id number: 55611 )

Policy contract number

500324

Policy instance

Insurance contract or identification number	500324
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 $7,215
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	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 $126,792
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,215
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

ANTHEM BLUE CROSS AND BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 71835 )

Policy contract number

L02782

Policy instance

Insurance contract or identification number	L02782
Number of Individuals Covered	136
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $45,573
Total amount of fees paid to insurance company	USD $18,987
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	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 $1,273,309
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,573
Amount paid for insurance broker fees	18987
Additional information about fees paid to insurance broker	GENERAL AGENT FEES, COMMISSIONS AND BONUS
Insurance broker organization code?	3

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1043505

Policy instance

Insurance contract or identification number	1043505
Number of Individuals Covered	114
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $9,901
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	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
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 $111,836
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,901
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	YUSHIRO MANUFACTURING AMERICA, INC.
Employer identification number (EIN):	621296001
NAIC Classification:	326100