401k Plan data: POTTER & SIMS FOODS, INC. HEALTH CARE PLAN plan

POTTER & SIMS FOODS, INC. HEALTH CARE PLAN 401k Plan overview

Plan Name	POTTER & SIMS FOODS, INC. HEALTH CARE PLAN
Plan identification number	501

POTTER & SIMS FOODS, INC. HEALTH CARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision)

401k Sponsoring company profile

POTTER & SIMS FOODS, INC. has sponsored the creation of one or more 401k plans.

Company Name: POTTER & SIMS FOODS, INC.

Employer identification number (EIN): 640806495

NAIC Classification: 445110
NAIC Description: Supermarkets and Other Grocery (except Convenience) Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan POTTER & SIMS FOODS, INC. HEALTH CARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2024-01-01 KATHY WATKINS
501 2023-01-01
501 2023-01-01 KATHY WATKINS
501 2022-01-01
501 2022-01-01 KATHY WATKINS
501 2021-01-01
501 2021-01-01 KATHY WATKINS
501 2020-01-01
501 2019-01-01
501 2018-01-01

Form 5500 Responses for POTTER & SIMS FOODS, INC. HEALTH CARE PLAN

2023: POTTER & SIMS FOODS, INC. HEALTH CARE PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2022: POTTER & SIMS FOODS, INC. HEALTH CARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: POTTER & SIMS FOODS, INC. HEALTH CARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: POTTER & SIMS FOODS, INC. HEALTH CARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: POTTER & SIMS FOODS, INC. HEALTH CARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2018: POTTER & SIMS FOODS, INC. HEALTH CARE PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417003411096

Policy instance

1

Insurance contract or identification number	417003411096
Number of Individuals Covered	31
Insurance policy start date	2023-01-01
Insurance policy end date	2024-01-01
Total amount of commissions paid to insurance broker	USD $19,729
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $130,135
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417003411096

Policy instance

1

Insurance contract or identification number	417003411096
Number of Individuals Covered	40
Insurance policy start date	2022-01-01
Insurance policy end date	2023-01-01
Total amount of commissions paid to insurance broker	USD $23,039
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $154,736
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417003411096

Policy instance

1

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417003411096

Policy instance

1

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417003411096

Policy instance

1

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

417003411096

Policy instance

1

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