401k Plan data: GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN plan

GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 401k Plan overview

Plan Name	GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN
Plan identification number	001

GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Plan covering Self-Employed individuals.
Plan not intended to be qualified - A plan not intended to be qualified under Code sections 401, 403, or 408.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

GOMEZ HERMANOS KENNEDY, LLC has sponsored the creation of one or more 401k plans.

Company Name: GOMEZ HERMANOS KENNEDY, LLC

Employer identification number (EIN): 660504069

NAIC Classification: 441110
NAIC Description: New Car Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01 WILFREDO VARGAS BURGOS 2023-11-13
001 2021-01-01 WILFREDO VARGAS BURGOS 2023-02-14 WILFREDO VARGAS BURGOS 2023-02-14
001 2020-01-01 WILFREDO VARGAS BURGOS 2021-10-14 WILFREDO VARGAS BURGOS 2021-10-14
001 2019-01-01
001 2018-01-01
001 2017-01-01
001 2016-01-01 WILFREDO VARGAS BURGOS 2017-07-19 WILFREDO VARGAS BURGOS 2017-07-19
001 2016-01-01
001 2015-01-01 JEAN KARLO ROCAFORT 2016-07-28
001 2015-01-01
001 2014-01-01
001 2014-01-01 WILFREDO VARGAS-BURGOS 2015-07-30
001 2013-01-01
001 2012-01-01 HILDA MALDONADO 2013-06-07 HILDA MALDONADO 2013-06-07
001 2011-01-01 HILDA MALDONADO 2012-05-16 HILDA MALDONADO 2012-05-16
001 2010-01-01 HILDA MALDONADO 2011-07-28 HILDA MALDONADO 2011-07-28

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2022-01-01	WILFREDO VARGAS BURGOS	2023-11-13
001	2021-01-01	WILFREDO VARGAS BURGOS	2023-02-14	WILFREDO VARGAS BURGOS	2023-02-14
001	2020-01-01	WILFREDO VARGAS BURGOS	2021-10-14	WILFREDO VARGAS BURGOS	2021-10-14
001	2019-01-01
001	2018-01-01
001	2017-01-01
001	2016-01-01	WILFREDO VARGAS BURGOS	2017-07-19	WILFREDO VARGAS BURGOS	2017-07-19
001	2016-01-01
001	2015-01-01	JEAN KARLO ROCAFORT	2016-07-28
001	2015-01-01
001	2014-01-01
001	2014-01-01	WILFREDO VARGAS-BURGOS	2015-07-30
001	2013-01-01
001	2012-01-01	HILDA MALDONADO	2013-06-07	HILDA MALDONADO	2013-06-07
001	2011-01-01	HILDA MALDONADO	2012-05-16	HILDA MALDONADO	2012-05-16
001	2010-01-01	HILDA MALDONADO	2011-07-28	HILDA MALDONADO	2011-07-28

Plan Statistics for GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN

401k plan membership statisitcs for GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN

Measure Date Value
2022: GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 161
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 76
Number of retired or separated participants receiving benefits 2022-01-01 20
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 96
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 96
Number of participants with account balances 2022-01-01 75
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 173
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 149
Number of retired or separated participants receiving benefits 2021-01-01 12
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 161
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 161
Number of participants with account balances 2021-01-01 76
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 78
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 173
Number of retired or separated participants receiving benefits 2020-01-01 40
Total of all active and inactive participants 2020-01-01 213
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 213
Number of participants with account balances 2020-01-01 173
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0

Measure	Date	Value
2022: GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	161
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	76
Number of retired or separated participants receiving benefits	2022-01-01	20
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	96
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	96
Number of participants with account balances	2022-01-01	75
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	173
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	149
Number of retired or separated participants receiving benefits	2021-01-01	12
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	161
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	161
Number of participants with account balances	2021-01-01	76
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	78
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	173
Number of retired or separated participants receiving benefits	2020-01-01	40
Total of all active and inactive participants	2020-01-01	213
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	213
Number of participants with account balances	2020-01-01	173
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0

Financial Data on GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN

Measure	Date	Value
2022 : GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$1,107
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$9,015
Total income from all sources (including contributions)	2022-12-31	$-16,051
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$61,293
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$3,892
Expenses. Certain deemed distributions of participant loans	2022-12-31	$35,207
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$283,822
Value of total assets at end of year	2022-12-31	$1,666,188
Value of total assets at beginning of year	2022-12-31	$1,751,440
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$22,194
Total interest from all sources	2022-12-31	$1,520
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$84,186
Total dividends received from registered investment company shares (eg mutual funds)	2022-12-31	$84,186
Was this plan covered by a fidelity bond	2022-12-31	No
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$202,177
Participant contributions at end of year	2022-12-31	$0
Participant contributions at beginning of year	2022-12-31	$39,602
Participant contributions at end of year	2022-12-31	$29,911
Participant contributions at beginning of year	2022-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2022-12-31	$1,107
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2022-12-31	$9,015
Administrative expenses (other) incurred	2022-12-31	$22,194
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-77,344
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$1,665,081
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$1,742,425
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$1,595,028
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$1,684,082
Interest on participant loans	2022-12-31	$1,520
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$29,211
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$27,756
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-385,579
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$81,645
Employer contributions (assets) at end of year	2022-12-31	$12,038
Employer contributions (assets) at beginning of year	2022-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$3,892
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Disclaimer
Accountancy firm name	2022-12-31	RSM
Accountancy firm EIN	2022-12-31	660388756
2021 : GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$9,015
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$368,331
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$137,069
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$115,669
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$177,035
Value of total assets at end of year	2021-12-31	$1,751,440
Value of total assets at beginning of year	2021-12-31	$1,511,163
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$21,400
Total interest from all sources	2021-12-31	$1,021
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$97,708
Total dividends received from registered investment company shares (eg mutual funds)	2021-12-31	$97,708
Was this plan covered by a fidelity bond	2021-12-31	No
If this is an individual account plan, was there a blackout period	2021-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$116,217
Participant contributions at end of year	2021-12-31	$39,602
Participant contributions at beginning of year	2021-12-31	$5,885
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$1,018
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2021-12-31	$9,015
Administrative expenses (other) incurred	2021-12-31	$21,400
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$231,262
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$1,742,425
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$1,511,163
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$1,684,082
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$1,479,694
Interest on participant loans	2021-12-31	$1,021
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$27,756
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$25,584
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$92,567
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$59,800
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$115,669
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	RSM PUERTO RICO
Accountancy firm EIN	2021-12-31	660388756
2020 : GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$495,274
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$52,020
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$43,347
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$270,658
Value of total assets at end of year	2020-12-31	$1,511,163
Value of total assets at beginning of year	2020-12-31	$1,067,909
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$8,673
Total interest from all sources	2020-12-31	$571
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$62,135
Total dividends received from registered investment company shares (eg mutual funds)	2020-12-31	$62,135
Was this plan covered by a fidelity bond	2020-12-31	No
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$112,847
Participant contributions at end of year	2020-12-31	$5,885
Participant contributions at beginning of year	2020-12-31	$8,990
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$104,872
Administrative expenses (other) incurred	2020-12-31	$8,673
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$443,254
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$1,511,163
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$1,067,909
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$1,479,694
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$1,036,018
Interest on participant loans	2020-12-31	$571
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2020-12-31	$22,901
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2020-12-31	$22,901
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$25,584
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$161,910
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$52,939
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$43,347
Did the plan have assets held for investment	2020-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Disclaimer
Accountancy firm name	2020-12-31	RSM
Accountancy firm EIN	2020-12-31	660388756

Form 5500 Responses for GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN

2022: GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: GOMEZ HERMANOS KENNEDY, INC. PROFIT SHARING PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

511886-P1

Policy instance

Insurance contract or identification number	511886-P1
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $54
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?	Yes
Health Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27
Insurance broker organization code?	3

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

511886-P1

Policy instance

Insurance contract or identification number	511886-P1
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $52
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?	Yes
Health Insurance Welfare Benefit	No
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
Commission paid to Insurance Broker	USD $26
Insurance broker organization code?	3

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

511886-P1

Policy instance

Insurance contract or identification number	511886-P1
Number of Individuals Covered	2
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $25
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?	Yes
Health Insurance Welfare Benefit	No
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
Commission paid to Insurance Broker	USD $13
Insurance broker organization code?	3

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Company Name:	GOMEZ HERMANOS KENNEDY, LLC
Employer identification number (EIN):	660504069
NAIC Classification:	441110
NAIC Description:	New Car Dealers