401k Plan data: THE GOOD FOOD STORE GROUP HEALTH INSURANCE plan

THE GOOD FOOD STORE GROUP HEALTH INSURANCE 401k Plan overview

Plan Name	THE GOOD FOOD STORE GROUP HEALTH INSURANCE
Plan identification number	505

THE GOOD FOOD STORE GROUP HEALTH INSURANCE 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

GOOD FOOD STORE INC. has sponsored the creation of one or more 401k plans.

Company Name: GOOD FOOD STORE INC.

Employer identification number (EIN): 810468070

NAIC Classification: 445110
NAIC Description: Supermarkets and Other Grocery (except Convenience) Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan THE GOOD FOOD STORE GROUP HEALTH INSURANCE

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2022-01-01
505 2021-01-01

Plan Statistics for THE GOOD FOOD STORE GROUP HEALTH INSURANCE

401k plan membership statisitcs for THE GOOD FOOD STORE GROUP HEALTH INSURANCE

Measure Date Value
2022: THE GOOD FOOD STORE GROUP HEALTH INSURANCE 2022 401k membership
Total participants, beginning-of-year 2022-01-01 126
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 123
Total of all active and inactive participants 2022-01-01 123
Total participants 2022-01-01 123
2021: THE GOOD FOOD STORE GROUP HEALTH INSURANCE 2021 401k membership
Total participants, beginning-of-year 2021-01-01 0
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 313
Total of all active and inactive participants 2021-01-01 313
Total participants 2021-01-01 313

Measure	Date	Value
2022: THE GOOD FOOD STORE GROUP HEALTH INSURANCE 2022 401k membership
Total participants, beginning-of-year	2022-01-01	126
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	123
Total of all active and inactive participants	2022-01-01	123
Total participants	2022-01-01	123
2021: THE GOOD FOOD STORE GROUP HEALTH INSURANCE 2021 401k membership
Total participants, beginning-of-year	2021-01-01	0
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	313
Total of all active and inactive participants	2021-01-01	313
Total participants	2021-01-01	313

Form 5500 Responses for THE GOOD FOOD STORE GROUP HEALTH INSURANCE

2022: THE GOOD FOOD STORE GROUP HEALTH INSURANCE 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: THE GOOD FOOD STORE GROUP HEALTH INSURANCE 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

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCCLOT41244

Policy instance

Insurance contract or identification number	HCCLOT41244
Number of Individuals Covered	121
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Other welfare benefits provided	ORGAN TRANSPLANT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCL35908

Policy instance

Insurance contract or identification number	HCL35908
Number of Individuals Covered	126
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1126205

Policy instance

Insurance contract or identification number	1126205
Number of Individuals Covered	152
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,344
Total amount of fees paid to insurance company	USD $930
Dental Insurance Welfare Benefit	Yes
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 $3,344
Amount paid for insurance broker fees	930
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

602213

Policy instance

Insurance contract or identification number	602213
Number of Individuals Covered	153
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,711
Total amount of fees paid to insurance company	USD $1,024
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DIMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,339
Amount paid for insurance broker fees	959
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCCLOT41244

Policy instance

Insurance contract or identification number	HCCLOT41244
Number of Individuals Covered	131
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Other welfare benefits provided	ORGAN TRANSPLANT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HCC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 92711 )

Policy contract number

HCL35908

Policy instance

Insurance contract or identification number	HCL35908
Number of Individuals Covered	131
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1126205

Policy instance

Insurance contract or identification number	1126205
Number of Individuals Covered	153
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $3,102
Total amount of fees paid to insurance company	USD $3,630
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	3630
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Commission paid to Insurance Broker	USD $2,146

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

602213

Policy instance

Insurance contract or identification number	602213
Number of Individuals Covered	141
Insurance policy start date	2021-01-01
Insurance policy end date	2022-01-01
Total amount of commissions paid to insurance broker	USD $6,357
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DIMEMBERMENT
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,042
Insurance broker organization code?	3

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Company Name:	GOOD FOOD STORE INC.
Employer identification number (EIN):	810468070
NAIC Classification:	445110
NAIC Description:	Supermarkets and Other Grocery (except Convenience) Stores