401k Plan data: ADKINS ENTERPRISES BENEFIT PLAN plan

ADKINS ENTERPRISES BENEFIT PLAN 401k Plan overview

Plan Name	ADKINS ENTERPRISES BENEFIT PLAN
Plan identification number	501

ADKINS ENTERPRISES BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision Temporary disability (accident and sickness)

401k Sponsoring company profile

ADKINS ENTERPRISES, INC has sponsored the creation of one or more 401k plans.

Company Name: ADKINS ENTERPRISES, INC

Employer identification number (EIN): 731290475

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Additional information about ADKINS ENTERPRISES, INC

Jurisdiction of Incorporation: Colorado Department of State

Incorporation Date: 2015-12-22

Company Identification Number: 20151809345

Legal Registered Office Address: 14037 E Idaho Place

Aurora
United States of America (USA)
80012

More information about ADKINS ENTERPRISES, INC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ADKINS ENTERPRISES BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-03-01 DONNA SIMMONS
501 2012-10-01 DONNA SIMMONS
501 2011-10-01 DONNA SIMMONS

Plan id#	Filing Submission Date	Name of Administrator
501	2015-03-01	DONNA SIMMONS
501	2012-10-01	DONNA SIMMONS
501	2011-10-01	DONNA SIMMONS

Plan Statistics for ADKINS ENTERPRISES BENEFIT PLAN

401k plan membership statisitcs for ADKINS ENTERPRISES BENEFIT PLAN

Measure Date Value
2015: ADKINS ENTERPRISES BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-03-01 0
Total of all active and inactive participants 2015-03-01 0
Total participants 2015-03-01 0
2012: ADKINS ENTERPRISES BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-10-01 123
Total number of active participants reported on line 7a of the Form 5500 2012-10-01 123
Total of all active and inactive participants 2012-10-01 123
Total participants 2012-10-01 0
2011: ADKINS ENTERPRISES BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-10-01 1
Total number of active participants reported on line 7a of the Form 5500 2011-10-01 176
Total of all active and inactive participants 2011-10-01 176
Total participants 2011-10-01 176

Measure	Date	Value
2015: ADKINS ENTERPRISES BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-03-01	0
Total of all active and inactive participants	2015-03-01	0
Total participants	2015-03-01	0
2012: ADKINS ENTERPRISES BENEFIT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-10-01	123
Total number of active participants reported on line 7a of the Form 5500	2012-10-01	123
Total of all active and inactive participants	2012-10-01	123
Total participants	2012-10-01	0
2011: ADKINS ENTERPRISES BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-10-01	1
Total number of active participants reported on line 7a of the Form 5500	2011-10-01	176
Total of all active and inactive participants	2011-10-01	176
Total participants	2011-10-01	176

Form 5500 Responses for ADKINS ENTERPRISES BENEFIT PLAN

2015: ADKINS ENTERPRISES BENEFIT PLAN 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2012: ADKINS ENTERPRISES BENEFIT PLAN 2012 form 5500 responses
2012-10-01	Type of plan entity	Single employer plan
2012-10-01	Plan funding arrangement – Insurance	Yes
2012-10-01	Plan benefit arrangement – Insurance	Yes
2011: ADKINS ENTERPRISES BENEFIT PLAN 2011 form 5500 responses
2011-10-01	Type of plan entity	Single employer plan
2011-10-01	First time form 5500 has been submitted	Yes
2011-10-01	Plan funding arrangement – Insurance	Yes
2011-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 )

Policy contract number

SE085-ADKINS

Policy instance

Insurance contract or identification number	SE085-ADKINS
Number of Individuals Covered	57
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $10,355
Total amount of fees paid to insurance company	USD $88,682
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,355
Amount paid for insurance broker fees	88682
Additional information about fees paid to insurance broker	COMMISSION
Insurance broker organization code?	3
Insurance broker name	WAYNE PETTIGREW

PAN-AMERICAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67539 )

Policy contract number

97492

Policy instance

Insurance contract or identification number	97492
Number of Individuals Covered	49
Total amount of fees paid to insurance company	USD $59,078
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $99,534
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1340
Additional information about fees paid to insurance broker	CONVERSION FEES
Insurance broker organization code?	0
Insurance broker name	GILSBAR, INC

DELTA DENTAL (National Association of Insurance Commissioners NAIC id number: 53937 )

Policy contract number

8624-0022

Policy instance

Insurance contract or identification number	8624-0022
Number of Individuals Covered	38
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name	GAYLE WAYNE PETTIGREW

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

ADKINS ENTERPR

Policy instance

Insurance contract or identification number	ADKINS ENTERPR
Number of Individuals Covered	123
Total amount of fees paid to insurance company	USD $91
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $7,507
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	91
Insurance broker organization code?	3
Insurance broker name	GAYLE WAYNE PETTIGREW

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

ADKINS ENTERPR

Policy instance

Insurance contract or identification number	ADKINS ENTERPR
Number of Individuals Covered	32
Total amount of commissions paid to insurance broker	USD $1,572
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,872
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

ADKINS ENTERPR

Policy instance

Insurance contract or identification number	ADKINS ENTERPR
Number of Individuals Covered	4
Total amount of commissions paid to insurance broker	USD $661
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,512
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

ADKINS ENTERPR

Policy instance

Insurance contract or identification number	ADKINS ENTERPR
Number of Individuals Covered	140
Total amount of commissions paid to insurance broker	USD $534
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $6,671
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	ADKINS ENTERPRISES, INC
Employer identification number (EIN):	731290475
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities

Jurisdiction of Incorporation:	Colorado Department of State
Incorporation Date:	2015-12-22
Company Identification Number:	20151809345
Legal Registered Office Address:	14037 E Idaho Place Aurora United States of America (USA) 80012