401k Plan data: CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN plan

CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 401k Plan overview

Plan Name	CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN
Plan identification number	001

CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
Profit-sharing
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.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
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

CAPITAL CITY DRYWALL INC has sponsored the creation of one or more 401k plans.

Company Name: CAPITAL CITY DRYWALL INC

Employer identification number (EIN): 680461321

NAIC Classification: 238300

Additional information about CAPITAL CITY DRYWALL INC

Jurisdiction of Incorporation: Idaho Secretary Of State

Incorporation Date:

Company Identification Number: C129637

More information about CAPITAL CITY DRYWALL INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CAPITAL CITY DRYWALL INC 401K 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 JUDY D HALES 2023-10-13
001 2021-01-01 JUDY D. HALES 2022-10-14
001 2020-01-01 JUDY D. HALES 2021-10-09 JUDY D. HALES 2021-10-09
001 2019-01-01 ANDREW D SELLERS 2020-10-09 ANDREW D SELLERS 2020-10-09

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2022-01-01			JUDY D HALES	2023-10-13
001	2021-01-01	JUDY D. HALES	2022-10-14
001	2020-01-01	JUDY D. HALES	2021-10-09	JUDY D. HALES	2021-10-09
001	2019-01-01	ANDREW D SELLERS	2020-10-09	ANDREW D SELLERS	2020-10-09

Plan Statistics for CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN

401k plan membership statisitcs for CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN

Measure Date Value
2022: CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 428
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 359
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 6
Total of all active and inactive participants 2022-01-01 365
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 365
Number of participants with account balances 2022-01-01 44
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 393
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 455
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 3
Total of all active and inactive participants 2021-01-01 458
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 458
Number of participants with account balances 2021-01-01 43
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 361
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 367
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 367
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 367
Number of participants with account balances 2020-01-01 33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 272
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 318
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 318
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 318
Number of participants with account balances 2019-01-01 26
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0

Measure	Date	Value
2022: CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	428
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	359
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	6
Total of all active and inactive participants	2022-01-01	365
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	365
Number of participants with account balances	2022-01-01	44
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	393
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	455
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	3
Total of all active and inactive participants	2021-01-01	458
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	458
Number of participants with account balances	2021-01-01	43
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	361
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	367
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	367
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	367
Number of participants with account balances	2020-01-01	33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	272
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	318
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	318
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	318
Number of participants with account balances	2019-01-01	26
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0

Financial Data on CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN

Measure	Date	Value
2022 : CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2022 401k financial data
Total income from all sources (including contributions)	2022-12-31	$244,657
Total of all expenses incurred	2022-12-31	$182,973
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$163,933
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$466,662
Value of total assets at end of year	2022-12-31	$1,234,624
Value of total assets at beginning of year	2022-12-31	$1,172,940
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$19,040
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Administrative expenses professional fees incurred	2022-12-31	$600
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$225,000
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	$315,547
Participant contributions at beginning of year	2022-12-31	$323
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	$61,684
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$1,234,624
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$1,172,940
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
Investment advisory and management fees	2022-12-31	$18,440
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$1,234,624
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$1,172,617
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-222,005
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	No
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	$151,115
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$163,933
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	Unqualified
Accountancy firm name	2022-12-31	LEE CPA AUDIT GROUP
Accountancy firm EIN	2022-12-31	814637885
2021 : CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2021 401k financial data
Total income from all sources (including contributions)	2021-12-31	$575,241
Total of all expenses incurred	2021-12-31	$17,773
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$2,743
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$418,599
Value of total assets at end of year	2021-12-31	$1,172,940
Value of total assets at beginning of year	2021-12-31	$615,472
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$15,030
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Administrative expenses professional fees incurred	2021-12-31	$75
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$225,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$278,062
Participant contributions at end of year	2021-12-31	$323
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
Income. Non cash contributions	2021-12-31	$0
Value of net income/loss	2021-12-31	$557,468
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$1,172,940
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$615,472
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
Investment advisory and management fees	2021-12-31	$14,955
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$1,172,617
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$615,472
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$156,642
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	$140,537
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$2,743
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	LEE CPA AUDIT GROUP
Accountancy firm EIN	2021-12-31	814637885
2020 : CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2020 401k financial data
Total income from all sources (including contributions)	2020-12-31	$471,369
Total of all expenses incurred	2020-12-31	$12,946
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$5,276
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$357,552
Value of total assets at end of year	2020-12-31	$615,472
Value of total assets at beginning of year	2020-12-31	$157,049
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$7,670
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$225,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2020-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$242,963
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	$458,423
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$615,472
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$157,049
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
Investment advisory and management fees	2020-12-31	$7,670
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$615,472
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$157,049
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$113,817
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	$114,589
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$5,276
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	LEE CPA AUDIT GROUP
Accountancy firm EIN	2020-12-31	814637885
2019 : CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2019 401k financial data
Total income from all sources (including contributions)	2019-12-31	$157,049
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$157,067
Value of total assets at end of year	2019-12-31	$157,049
Value of total assets at beginning of year	2019-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-12-31	No
Was this plan covered by a fidelity bond	2019-12-31	No
If this is an individual account plan, was there a blackout period	2019-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$106,614
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$157,049
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$157,049
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$157,049
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$-18
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Contributions received in cash from employer	2019-12-31	$50,453
Did the plan have assets held for investment	2019-12-31	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	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	LEE CPA AUDIT GROUP
Accountancy firm EIN	2019-12-31	814637885

Form 5500 Responses for CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN

2022: CAPITAL CITY DRYWALL INC 401K 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 – Insurance	Yes
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: CAPITAL CITY DRYWALL INC 401K 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 – Insurance	Yes
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: CAPITAL CITY DRYWALL INC 401K 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 – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: CAPITAL CITY DRYWALL INC 401K PROFIT SHARING PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	First time form 5500 has been submitted	Yes
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

141925

Policy instance

Insurance contract or identification number	141925
Number of Individuals Covered	46
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,926
Total amount of fees paid to insurance company	USD $594
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,926
Insurance broker organization code?	4
Amount paid for insurance broker fees	594

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

141925

Policy instance

Insurance contract or identification number	141925
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $4,359
Total amount of fees paid to insurance company	USD $456
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,359
Insurance broker organization code?	4
Amount paid for insurance broker fees	456

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

141925

Policy instance

Insurance contract or identification number	141925
Number of Individuals Covered	41
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,856
Total amount of fees paid to insurance company	USD $4,964
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,856
Insurance broker organization code?	4
Amount paid for insurance broker fees	4964

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

141925

Policy instance

Insurance contract or identification number	141925
Number of Individuals Covered	34
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CAPITAL CITY DRYWALL INC
Employer identification number (EIN):	680461321
NAIC Classification:	238300

Jurisdiction of Incorporation:	Idaho Secretary Of State
Incorporation Date:
Company Identification Number:	C129637