401k Plan data: R.W. GARCIA CO., INC. HEALTH AND WELFARE PLAN plan

R.W. GARCIA CO., INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	R.W. GARCIA CO., INC. HEALTH AND WELFARE PLAN
Plan identification number	502

R.W. GARCIA CO., 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 Other welfare benefit cover

401k Sponsoring company profile

R.W. GARCIA CO., INC. has sponsored the creation of one or more 401k plans.

Company Name: R.W. GARCIA CO., INC.

Employer identification number (EIN): 770121675

NAIC Classification: 311800
NAIC Description: Bakeries and Tortilla Manufacturing

Form 5500 Filing Information

Submission information for form 5500 for 401k plan R.W. GARCIA CO., INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2021-10-01 ALICIA HENRY 2022-10-11

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2021-10-01	ALICIA HENRY	2022-10-11

Plan Statistics for R.W. GARCIA CO., INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for R.W. GARCIA CO., INC. HEALTH AND WELFARE PLAN

Measure Date Value
2021: R.W. GARCIA CO., INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-10-01 146
Total number of active participants reported on line 7a of the Form 5500 2021-10-01 164
Number of retired or separated participants receiving benefits 2021-10-01 0
Number of other retired or separated participants entitled to future benefits 2021-10-01 0
Total of all active and inactive participants 2021-10-01 164

Measure	Date	Value
2021: R.W. GARCIA CO., INC. HEALTH AND WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-10-01	146
Total number of active participants reported on line 7a of the Form 5500	2021-10-01	164
Number of retired or separated participants receiving benefits	2021-10-01	0
Number of other retired or separated participants entitled to future benefits	2021-10-01	0
Total of all active and inactive participants	2021-10-01	164

Form 5500 Responses for R.W. GARCIA CO., INC. HEALTH AND WELFARE PLAN

2021: R.W. GARCIA CO., INC. HEALTH AND WELFARE PLAN 2021 form 5500 responses
2021-10-01	Type of plan entity	Single employer plan
2021-10-01	First time form 5500 has been submitted	Yes
2021-10-01	Submission has been amended	No
2021-10-01	This submission is the final filing	No
2021-10-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2021-10-01	Plan is a collectively bargained plan	No
2021-10-01	Plan funding arrangement – Insurance	Yes
2021-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

279054

Policy instance

Insurance contract or identification number	279054
Number of Individuals Covered	171
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $55,921
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	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
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 $1,047,083
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $55,921
Insurance broker organization code?	3

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

Policy contract number

00556485

Policy instance

Insurance contract or identification number	00556485
Number of Individuals Covered	35
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,494
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	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	ACCIDENT, AD&D
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 $26,022
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,427
Insurance broker organization code?	3

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Company Name:	R.W. GARCIA CO., INC.
Employer identification number (EIN):	770121675
NAIC Classification:	311800
NAIC Description:	Bakeries and Tortilla Manufacturing