401k Plan data: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS plan

BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 401k Plan overview

Plan Name	BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS
Plan identification number	514

BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

BS&B SAFETY SYSTEMS, LLC has sponsored the creation of one or more 401k plans.

Company Name: BS&B SAFETY SYSTEMS, LLC

Employer identification number (EIN): 730785967

NAIC Classification: 332900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
514 2014-09-01 CHARLES HART CHARLES HART 2016-03-07
514 2014-09-01
514 2013-09-01 CHARLES HART
514 2012-09-01 CHARLES HART ARTHUR HUSE 2014-01-15
514 2011-09-01 CHARLES HART ARTHUR HUSE 2013-03-28

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
514	2014-09-01	CHARLES HART	CHARLES HART	2016-03-07
514	2014-09-01
514	2013-09-01	CHARLES HART
514	2012-09-01	CHARLES HART	ARTHUR HUSE	2014-01-15
514	2011-09-01	CHARLES HART	ARTHUR HUSE	2013-03-28

Plan Statistics for BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS

401k plan membership statisitcs for BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS

Measure Date Value
2014: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2014 401k membership
Total participants, beginning-of-year 2014-09-01 130
Total number of active participants reported on line 7a of the Form 5500 2014-09-01 130
Number of retired or separated participants receiving benefits 2014-09-01 0
Number of other retired or separated participants entitled to future benefits 2014-09-01 0
Total of all active and inactive participants 2014-09-01 130
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-09-01 0
Total participants 2014-09-01 130
Number of participants with account balances 2014-09-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-09-01 0
2013: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2013 401k membership
Total participants, beginning-of-year 2013-09-01 135
Total number of active participants reported on line 7a of the Form 5500 2013-09-01 135
Number of retired or separated participants receiving benefits 2013-09-01 0
Number of other retired or separated participants entitled to future benefits 2013-09-01 0
Total of all active and inactive participants 2013-09-01 135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-09-01 0
Total participants 2013-09-01 135
Number of participants with account balances 2013-09-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-09-01 0
2012: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2012 401k membership
Total participants, beginning-of-year 2012-09-01 135
Total number of active participants reported on line 7a of the Form 5500 2012-09-01 135
Number of retired or separated participants receiving benefits 2012-09-01 0
Number of other retired or separated participants entitled to future benefits 2012-09-01 0
Total of all active and inactive participants 2012-09-01 135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-09-01 0
Total participants 2012-09-01 135
Number of participants with account balances 2012-09-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-09-01 0
2011: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2011 401k membership
Total participants, beginning-of-year 2011-09-01 135
Total number of active participants reported on line 7a of the Form 5500 2011-09-01 135
Number of retired or separated participants receiving benefits 2011-09-01 0
Number of other retired or separated participants entitled to future benefits 2011-09-01 0
Total of all active and inactive participants 2011-09-01 135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-09-01 0
Total participants 2011-09-01 135
Number of participants with account balances 2011-09-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-09-01 0

Measure	Date	Value
2014: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2014 401k membership
Total participants, beginning-of-year	2014-09-01	130
Total number of active participants reported on line 7a of the Form 5500	2014-09-01	130
Number of retired or separated participants receiving benefits	2014-09-01	0
Number of other retired or separated participants entitled to future benefits	2014-09-01	0
Total of all active and inactive participants	2014-09-01	130
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-09-01	0
Total participants	2014-09-01	130
Number of participants with account balances	2014-09-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-09-01	0
2013: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2013 401k membership
Total participants, beginning-of-year	2013-09-01	135
Total number of active participants reported on line 7a of the Form 5500	2013-09-01	135
Number of retired or separated participants receiving benefits	2013-09-01	0
Number of other retired or separated participants entitled to future benefits	2013-09-01	0
Total of all active and inactive participants	2013-09-01	135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-09-01	0
Total participants	2013-09-01	135
Number of participants with account balances	2013-09-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-09-01	0
2012: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2012 401k membership
Total participants, beginning-of-year	2012-09-01	135
Total number of active participants reported on line 7a of the Form 5500	2012-09-01	135
Number of retired or separated participants receiving benefits	2012-09-01	0
Number of other retired or separated participants entitled to future benefits	2012-09-01	0
Total of all active and inactive participants	2012-09-01	135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-09-01	0
Total participants	2012-09-01	135
Number of participants with account balances	2012-09-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-09-01	0
2011: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2011 401k membership
Total participants, beginning-of-year	2011-09-01	135
Total number of active participants reported on line 7a of the Form 5500	2011-09-01	135
Number of retired or separated participants receiving benefits	2011-09-01	0
Number of other retired or separated participants entitled to future benefits	2011-09-01	0
Total of all active and inactive participants	2011-09-01	135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-09-01	0
Total participants	2011-09-01	135
Number of participants with account balances	2011-09-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-09-01	0

Form 5500 Responses for BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS

2014: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2014 form 5500 responses
2014-09-01	Type of plan entity	Single employer plan
2014-09-01	Submission has been amended	No
2014-09-01	This submission is the final filing	No
2014-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-09-01	Plan is a collectively bargained plan	No
2014-09-01	Plan funding arrangement – Insurance	Yes
2014-09-01	Plan benefit arrangement – Insurance	Yes
2013: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2013 form 5500 responses
2013-09-01	Type of plan entity	Single employer plan
2013-09-01	Submission has been amended	No
2013-09-01	This submission is the final filing	No
2013-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-09-01	Plan is a collectively bargained plan	No
2013-09-01	Plan funding arrangement – Insurance	Yes
2013-09-01	Plan benefit arrangement – Insurance	Yes
2012: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2012 form 5500 responses
2012-09-01	Type of plan entity	Single employer plan
2012-09-01	Submission has been amended	No
2012-09-01	This submission is the final filing	No
2012-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-09-01	Plan is a collectively bargained plan	No
2012-09-01	Plan funding arrangement – Insurance	Yes
2012-09-01	Plan benefit arrangement – Insurance	Yes
2011: BS&B ADD AND ACCIDENTAL MEDICAL BENEFITS 2011 form 5500 responses
2011-09-01	Type of plan entity	Single employer plan
2011-09-01	First time form 5500 has been submitted	Yes
2011-09-01	Submission has been amended	No
2011-09-01	This submission is the final filing	No
2011-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-09-01	Plan is a collectively bargained plan	No
2011-09-01	Plan funding arrangement – Insurance	Yes
2011-09-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

FEDERAL INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 20281 )

Policy contract number

000099067487

Policy instance

Insurance contract or identification number	000099067487
Number of Individuals Covered	130
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $588
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	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D AND ACCIDENTAL MEDICAL BENEFITS
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 $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $588
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	BS&B SAFETY SYSTEMS, LLC
Employer identification number (EIN):	730785967
NAIC Classification:	332900