401k Plan data: EMPIRE EQUIPMENT COMPANY, LLC ERISA WRAP PLAN plan

EMPIRE EQUIPMENT COMPANY, LLC ERISA WRAP PLAN 401k Plan overview

Plan Name	EMPIRE EQUIPMENT COMPANY, LLC ERISA WRAP PLAN
Plan identification number	501

EMPIRE EQUIPMENT COMPANY, LLC ERISA WRAP 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

EMPIRE EQUIPMENT COMPANY, LLC has sponsored the creation of one or more 401k plans.

Company Name: EMPIRE EQUIPMENT COMPANY, LLC

Employer identification number (EIN): 810867472

NAIC Classification: 493100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPIRE EQUIPMENT COMPANY, LLC ERISA WRAP PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01
501 2023-01-01 MARISSA BREY
501 2022-01-01
501 2022-01-01 KEITH BILYEU
501 2021-01-01
501 2021-01-01 KEITH BILYEU

Form 5500 Responses for EMPIRE EQUIPMENT COMPANY, LLC ERISA WRAP PLAN

2023: EMPIRE EQUIPMENT COMPANY, LLC ERISA WRAP 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: EMPIRE EQUIPMENT COMPANY, LLC ERISA WRAP 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: EMPIRE EQUIPMENT COMPANY, LLC ERISA WRAP 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

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

45849000

Policy instance

Insurance contract or identification number	45849000
Number of Individuals Covered	49
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $9,735
Total amount of fees paid to insurance company	USD $3,894
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $194,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

292160

Policy instance

Insurance contract or identification number	292160
Number of Individuals Covered	9
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,967
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $79,109
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

041385

Policy instance

Insurance contract or identification number	041385
Number of Individuals Covered	33
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $5,783
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $319,716
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

606908

Policy instance

Insurance contract or identification number	606908
Number of Individuals Covered	14
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $5,892
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $120,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

235134

Policy instance

Insurance contract or identification number	235134
Number of Individuals Covered	47
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $16,263
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $330,127
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

00558988

Policy instance

Insurance contract or identification number	00558988
Number of Individuals Covered	210
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $42,244
Total amount of fees paid to insurance company	USD $8,651
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
Other welfare benefits provided	AD&D, ACCIDENT, CANCER, VOL. CI & H
Welfare Benefit Premiums Paid to Carrier	USD $257,467
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

14172417

Policy instance

Insurance contract or identification number	14172417
Number of Individuals Covered	43
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $429,152
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

041385

Policy instance

Insurance contract or identification number	041385
Number of Individuals Covered	29
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,053
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $235,156
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

606908

Policy instance

Insurance contract or identification number	606908
Number of Individuals Covered	14
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $5,731
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $114,168
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

235134

Policy instance

Insurance contract or identification number	235134
Number of Individuals Covered	52
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $19,346
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $424,680
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

00558988

Policy instance

Insurance contract or identification number	00558988
Number of Individuals Covered	143
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $29,333
Total amount of fees paid to insurance company	USD $8,226
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
Other welfare benefits provided	AD&D, ACCIDENT, CANCER, VOL. CI & H
Welfare Benefit Premiums Paid to Carrier	USD $183,851
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUECROSS BLUESHIELD OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54631 )

Policy contract number

14172417

Policy instance

Insurance contract or identification number	14172417
Number of Individuals Covered	53
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $20,554
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $560,969
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

606908

Policy instance

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

235134

Policy instance

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

Policy contract number

00558988

Policy instance

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

00631240

Policy instance

Potentially related plans

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Company Name:	EMPIRE EQUIPMENT COMPANY, LLC
Employer identification number (EIN):	810867472
NAIC Classification:	493100

Plan id#	Filing Submission Date	Name of Administrator
501	2023-01-01
501	2023-01-01	MARISSA BREY
501	2022-01-01
501	2022-01-01	KEITH BILYEU
501	2021-01-01
501	2021-01-01	KEITH BILYEU