401k Plan data: MIKE CALVERT TOYOTA, INC. HEALTH AND WELFARE PLAN plan

MIKE CALVERT TOYOTA, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	MIKE CALVERT TOYOTA, INC. HEALTH AND WELFARE PLAN
Plan identification number	501

MIKE CALVERT TOYOTA, INC. HEALTH AND 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) Other welfare benefit cover

401k Sponsoring company profile

MIKE CALVERT, LLC has sponsored the creation of one or more 401k plans.

Company Name: MIKE CALVERT, LLC

Employer identification number (EIN): 760064949

NAIC Classification: 441110
NAIC Description: New Car Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MIKE CALVERT TOYOTA, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 RUBEN PERUMBEL 2024-06-13
501 2022-01-01 RUBEN PERUMBEL 2023-07-25
501 2021-01-01 VIC WALKER 2022-09-06

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2023-01-01	RUBEN PERUMBEL	2024-06-13
501	2022-01-01	RUBEN PERUMBEL	2023-07-25
501	2021-01-01	VIC WALKER	2022-09-06

Form 5500 Responses for MIKE CALVERT TOYOTA, INC. HEALTH AND WELFARE PLAN

2023: MIKE CALVERT TOYOTA, INC. HEALTH AND 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 benefit arrangement – Insurance	Yes
2022: MIKE CALVERT TOYOTA, INC. HEALTH AND 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 benefit arrangement – Insurance	Yes
2021: MIKE CALVERT TOYOTA, INC. HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	First time form 5500 has been submitted	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

350148

Policy instance

Insurance contract or identification number	350148
Number of Individuals Covered	330
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $88,608
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,428,896
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

GLUG0C6ZG

Policy instance

Insurance contract or identification number	GLUG0C6ZG
Number of Individuals Covered	209
Insurance policy start date	2022-11-01
Insurance policy end date	2023-10-31
Total amount of commissions paid to insurance broker	USD $19,506
Total amount of fees paid to insurance company	USD $10,839
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
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,CRITICAL ILLNESS,ACCIDENT,EMPLOYEE ASSISTANCE PROGRAM,HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $172,738
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA HEALTH, INC. (National Association of Insurance Commissioners NAIC id number: 95490 )

Policy contract number

143402HNO

Policy instance

Insurance contract or identification number	143402HNO
Number of Individuals Covered	157
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $38,077
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $939,212
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

246889

Policy instance

Insurance contract or identification number	246889
Number of Individuals Covered	163
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $6,640
Total amount of fees paid to insurance company	USD $458
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $89,287
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

143402

Policy instance

Insurance contract or identification number	143402
Number of Individuals Covered	153
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $25,521
Total amount of fees paid to insurance company	USD $16
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,103,079
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5912166

Policy instance

Insurance contract or identification number	5912166
Number of Individuals Covered	335
Insurance policy start date	2021-11-01
Insurance policy end date	2022-10-31
Total amount of commissions paid to insurance broker	USD $26,785
Total amount of fees paid to insurance company	USD $2,326
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, EMPLOYEE ASSISTANCE PROGRAM,CRITICAL ILLNESS,ACCIDENT,HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $149,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

143402HNO

Policy instance

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

246889

Policy instance

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5912166

Policy instance

Potentially related plans

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Company Name:	MIKE CALVERT, LLC
Employer identification number (EIN):	760064949
NAIC Classification:	441110
NAIC Description:	New Car Dealers