401k Plan data: UTILITY TRI-STATE, INC. WELFARE PLAN plan

UTILITY TRI-STATE, INC. WELFARE PLAN 401k Plan overview

Plan Name	UTILITY TRI-STATE, INC. WELFARE PLAN
Plan identification number	501

UTILITY TRI-STATE, INC. WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

UTILITY TRI-STATE, INC. has sponsored the creation of one or more 401k plans.

Company Name: UTILITY TRI-STATE, INC.

Employer identification number (EIN): 731312253

NAIC Classification: 423100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UTILITY TRI-STATE, INC. WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 JOHN BELIE 2024-05-31
501 2022-01-01 JOHN BELIE 2023-10-13
501 2021-12-01 JOHN BELIE 2023-10-13
501 2020-12-01 JOHN BELIE 2024-05-13
501 2019-12-01 JOHN BELIE 2024-05-13
501 2018-12-01 JOHN BELIE 2024-05-13
501 2017-12-01 JOHN BELIE 2024-05-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2023-01-01	JOHN BELIE	2024-05-31
501	2022-01-01	JOHN BELIE	2023-10-13
501	2021-12-01	JOHN BELIE	2023-10-13
501	2020-12-01	JOHN BELIE	2024-05-13
501	2019-12-01	JOHN BELIE	2024-05-13
501	2018-12-01	JOHN BELIE	2024-05-13
501	2017-12-01	JOHN BELIE	2024-05-13

Plan Statistics for UTILITY TRI-STATE, INC. WELFARE PLAN

401k plan membership statisitcs for UTILITY TRI-STATE, INC. WELFARE PLAN

Measure Date Value
2023: UTILITY TRI-STATE, INC. WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 183
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 213
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 213
Number of employers contributing to the scheme 2023-01-01 0
2022: UTILITY TRI-STATE, INC. WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 183
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 0
Total of all active and inactive participants 2022-01-01 183
Number of employers contributing to the scheme 2022-01-01 0
2021: UTILITY TRI-STATE, INC. WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-12-01 127
Total number of active participants reported on line 7a of the Form 5500 2021-12-01 129
Number of retired or separated participants receiving benefits 2021-12-01 0
Number of other retired or separated participants entitled to future benefits 2021-12-01 0
Total of all active and inactive participants 2021-12-01 129
Number of employers contributing to the scheme 2021-12-01 0
2020: UTILITY TRI-STATE, INC. WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-12-01 107
Total number of active participants reported on line 7a of the Form 5500 2020-12-01 127
Number of retired or separated participants receiving benefits 2020-12-01 0
Number of other retired or separated participants entitled to future benefits 2020-12-01 0
Total of all active and inactive participants 2020-12-01 127
Number of employers contributing to the scheme 2020-12-01 0
2019: UTILITY TRI-STATE, INC. WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-12-01 104
Total number of active participants reported on line 7a of the Form 5500 2019-12-01 107
Number of retired or separated participants receiving benefits 2019-12-01 0
Number of other retired or separated participants entitled to future benefits 2019-12-01 0
Total of all active and inactive participants 2019-12-01 107
Number of employers contributing to the scheme 2019-12-01 0
2018: UTILITY TRI-STATE, INC. WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-12-01 100
Total number of active participants reported on line 7a of the Form 5500 2018-12-01 104
Number of retired or separated participants receiving benefits 2018-12-01 0
Number of other retired or separated participants entitled to future benefits 2018-12-01 0
Total of all active and inactive participants 2018-12-01 104
Number of employers contributing to the scheme 2018-12-01 0
2017: UTILITY TRI-STATE, INC. WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-12-01 100
Total number of active participants reported on line 7a of the Form 5500 2017-12-01 104
Number of retired or separated participants receiving benefits 2017-12-01 0
Number of other retired or separated participants entitled to future benefits 2017-12-01 0
Total of all active and inactive participants 2017-12-01 104
Number of employers contributing to the scheme 2017-12-01 0

Measure	Date	Value
2023: UTILITY TRI-STATE, INC. WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	183
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	213
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	213
Number of employers contributing to the scheme	2023-01-01	0
2022: UTILITY TRI-STATE, INC. WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	183
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	0
Total of all active and inactive participants	2022-01-01	183
Number of employers contributing to the scheme	2022-01-01	0
2021: UTILITY TRI-STATE, INC. WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-12-01	127
Total number of active participants reported on line 7a of the Form 5500	2021-12-01	129
Number of retired or separated participants receiving benefits	2021-12-01	0
Number of other retired or separated participants entitled to future benefits	2021-12-01	0
Total of all active and inactive participants	2021-12-01	129
Number of employers contributing to the scheme	2021-12-01	0
2020: UTILITY TRI-STATE, INC. WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-12-01	107
Total number of active participants reported on line 7a of the Form 5500	2020-12-01	127
Number of retired or separated participants receiving benefits	2020-12-01	0
Number of other retired or separated participants entitled to future benefits	2020-12-01	0
Total of all active and inactive participants	2020-12-01	127
Number of employers contributing to the scheme	2020-12-01	0
2019: UTILITY TRI-STATE, INC. WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-12-01	104
Total number of active participants reported on line 7a of the Form 5500	2019-12-01	107
Number of retired or separated participants receiving benefits	2019-12-01	0
Number of other retired or separated participants entitled to future benefits	2019-12-01	0
Total of all active and inactive participants	2019-12-01	107
Number of employers contributing to the scheme	2019-12-01	0
2018: UTILITY TRI-STATE, INC. WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-12-01	100
Total number of active participants reported on line 7a of the Form 5500	2018-12-01	104
Number of retired or separated participants receiving benefits	2018-12-01	0
Number of other retired or separated participants entitled to future benefits	2018-12-01	0
Total of all active and inactive participants	2018-12-01	104
Number of employers contributing to the scheme	2018-12-01	0
2017: UTILITY TRI-STATE, INC. WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-12-01	100
Total number of active participants reported on line 7a of the Form 5500	2017-12-01	104
Number of retired or separated participants receiving benefits	2017-12-01	0
Number of other retired or separated participants entitled to future benefits	2017-12-01	0
Total of all active and inactive participants	2017-12-01	104
Number of employers contributing to the scheme	2017-12-01	0

Form 5500 Responses for UTILITY TRI-STATE, INC. WELFARE PLAN

2023: UTILITY TRI-STATE, INC. WELFARE 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 funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: UTILITY TRI-STATE, INC. WELFARE 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 funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2021: UTILITY TRI-STATE, INC. WELFARE PLAN 2021 form 5500 responses
2021-12-01	Type of plan entity	Single employer plan
2021-12-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2021-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-12-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: UTILITY TRI-STATE, INC. WELFARE PLAN 2020 form 5500 responses
2020-12-01	Type of plan entity	Single employer plan
2020-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2020-12-01	Plan benefit arrangement – General assets of the sponsor	Yes
2019: UTILITY TRI-STATE, INC. WELFARE PLAN 2019 form 5500 responses
2019-12-01	Type of plan entity	Single employer plan
2019-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-12-01	Plan benefit arrangement – General assets of the sponsor	Yes
2018: UTILITY TRI-STATE, INC. WELFARE PLAN 2018 form 5500 responses
2018-12-01	Type of plan entity	Single employer plan
2018-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-12-01	Plan benefit arrangement – General assets of the sponsor	Yes
2017: UTILITY TRI-STATE, INC. WELFARE PLAN 2017 form 5500 responses
2017-12-01	Type of plan entity	Single employer plan
2017-12-01	First time form 5500 has been submitted	Yes
2017-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-12-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

8255

Policy instance

Insurance contract or identification number	8255
Number of Individuals Covered	158
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $6,335
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30062670

Policy instance

Insurance contract or identification number	30062670
Number of Individuals Covered	142
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $912
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,261
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GUDE0AYG5

Policy instance

Insurance contract or identification number	GUDE0AYG5
Number of Individuals Covered	37
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,992
Total amount of fees paid to insurance company	USD $671
Other welfare benefits provided	CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $17,598
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AYG5

Policy instance

Insurance contract or identification number	GLUG0AYG5
Number of Individuals Covered	213
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $21,865
Total amount of fees paid to insurance company	USD $5,529
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $142,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30062670

Policy instance

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

Policy contract number

8255

Policy instance

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0AYG5

Policy instance

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Company Name:	UTILITY TRI-STATE, INC.
Employer identification number (EIN):	731312253
NAIC Classification:	423100