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| Plan Name | CROSSROADS SERVICES GROUP MEDICAL BENEFITS PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | CROSSROADS SERVICES GROUP LLC |
| Employer identification number (EIN): | 800796803 |
| NAIC Classification: | 493100 |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2020-01-01 | JIN AN | 2021-07-02 | ||
| 501 | 2020-01-01 | JIN AN | 2022-09-14 | ||
| 501 | 2019-01-01 | JIN AN | 2020-10-06 | ||
| 501 | 2012-06-01 | JAMES MAXWELL | JAMES MAXWELL | 2013-06-27 | |
| 501 | 2011-01-01 | JAMES MAXWELL |
| Measure | Date | Value |
|---|---|---|
| 2020: CROSSROADS SERVICES GROUP MEDICAL BENEFITS PLAN 2020 401k membership | ||
| Total participants, beginning-of-year | 2020-01-01 | 121 |
| Total number of active participants reported on line 7a of the Form 5500 | 2020-01-01 | 184 |
| Number of retired or separated participants receiving benefits | 2020-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2020-01-01 | 0 |
| Total of all active and inactive participants | 2020-01-01 | 184 |
| Number of employers contributing to the scheme | 2020-01-01 | 0 |
| 2019: CROSSROADS SERVICES GROUP MEDICAL BENEFITS PLAN 2019 401k membership | ||
| Total participants, beginning-of-year | 2019-01-01 | 100 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 121 |
| Number of retired or separated participants receiving benefits | 2019-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2019-01-01 | 0 |
| Total of all active and inactive participants | 2019-01-01 | 121 |
| Number of employers contributing to the scheme | 2019-01-01 | 0 |
| 2012: CROSSROADS SERVICES GROUP MEDICAL BENEFITS PLAN 2012 401k membership | ||
| Total participants, beginning-of-year | 2012-06-01 | 61 |
| Total number of active participants reported on line 7a of the Form 5500 | 2012-06-01 | 67 |
| Total of all active and inactive participants | 2012-06-01 | 67 |
| Total participants | 2012-06-01 | 67 |
| 2011: CROSSROADS SERVICES GROUP MEDICAL BENEFITS PLAN 2011 401k membership | ||
| Total participants, beginning-of-year | 2011-01-01 | 173 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-01-01 | 76 |
| Total of all active and inactive participants | 2011-01-01 | 76 |
| Total participants | 2011-01-01 | 76 |
| 2020: CROSSROADS SERVICES GROUP MEDICAL BENEFITS PLAN 2020 form 5500 responses | ||
|---|---|---|
| 2020-01-01 | Type of plan entity | Single employer plan |
| 2020-01-01 | Submission has been amended | Yes |
| 2020-01-01 | Plan funding arrangement – Insurance | Yes |
| 2020-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2019: CROSSROADS SERVICES GROUP MEDICAL BENEFITS PLAN 2019 form 5500 responses | ||
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2012: CROSSROADS SERVICES GROUP MEDICAL BENEFITS PLAN 2012 form 5500 responses | ||
| 2012-06-01 | Type of plan entity | Single employer plan |
| 2012-06-01 | Submission has been amended | No |
| 2012-06-01 | This submission is the final filing | No |
| 2012-06-01 | This return/report is a short plan year return/report (less than 12 months) | Yes |
| 2012-06-01 | Plan is a collectively bargained plan | No |
| 2012-06-01 | Plan funding arrangement – Insurance | Yes |
| 2012-06-01 | Plan benefit arrangement – Insurance | Yes |
| 2011: CROSSROADS SERVICES GROUP MEDICAL BENEFITS PLAN 2011 form 5500 responses | ||
| 2011-01-01 | Type of plan entity | Single employer plan |
| 2011-01-01 | First time form 5500 has been submitted | Yes |
| 2011-01-01 | Submission has been amended | No |
| 2011-01-01 | This submission is the final filing | No |
| 2011-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-01-01 | Plan is a collectively bargained plan | No |
| 2011-01-01 | Plan funding arrangement – Insurance | Yes |
| 2011-01-01 | Plan benefit arrangement – Insurance | Yes |
| THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 ) | |||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 568481 | ||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||
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| MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 ) | |||||||||||||||||||||||||||||||||||||||||
| Policy contract number | GLUG0AVPS | ||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||
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