401k Plan data: KMJ ENTERPRISES FIANNA HILLS LLC WELFARE BENEFITS PLAN plan

KMJ ENTERPRISES FIANNA HILLS LLC WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	KMJ ENTERPRISES FIANNA HILLS LLC WELFARE BENEFITS PLAN
Plan identification number	501

KMJ ENTERPRISES FIANNA HILLS LLC WELFARE BENEFITS 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) Death benefits (include travel accident but not life insurance) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

KMJ ENTERPRISES FIANNA HILLS LLC has sponsored the creation of one or more 401k plans.

Company Name: KMJ ENTERPRISES FIANNA HILLS LLC

Employer identification number (EIN): 820571556

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KMJ ENTERPRISES FIANNA HILLS LLC WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-12-01 DON SCHAAP 2019-06-24

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2017-12-01	DON SCHAAP	2019-06-24

Plan Statistics for KMJ ENTERPRISES FIANNA HILLS LLC WELFARE BENEFITS PLAN

401k plan membership statisitcs for KMJ ENTERPRISES FIANNA HILLS LLC WELFARE BENEFITS PLAN

Measure Date Value
2017: KMJ ENTERPRISES FIANNA HILLS LLC WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-12-01 106
Total number of active participants reported on line 7a of the Form 5500 2017-12-01 97
Number of retired or separated participants receiving benefits 2017-12-01 0
Number of other retired or separated participants entitled to future benefits 2017-12-01 0
Total of all active and inactive participants 2017-12-01 97
Number of employers contributing to the scheme 2017-12-01 0

Measure	Date	Value
2017: KMJ ENTERPRISES FIANNA HILLS LLC WELFARE BENEFITS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-12-01	106
Total number of active participants reported on line 7a of the Form 5500	2017-12-01	97
Number of retired or separated participants receiving benefits	2017-12-01	0
Number of other retired or separated participants entitled to future benefits	2017-12-01	0
Total of all active and inactive participants	2017-12-01	97
Number of employers contributing to the scheme	2017-12-01	0

Form 5500 Responses for KMJ ENTERPRISES FIANNA HILLS LLC WELFARE BENEFITS PLAN

2017: KMJ ENTERPRISES FIANNA HILLS LLC WELFARE BENEFITS PLAN 2017 form 5500 responses
2017-12-01	Type of plan entity	Single employer plan
2017-12-01	First time form 5500 has been submitted	Yes
2017-12-01	Plan funding arrangement – Insurance	Yes
2017-12-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

QCA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95448 )

Policy contract number

53525

Policy instance

Insurance contract or identification number	53525
Number of Individuals Covered	69
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $12,638
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $274,187
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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

Policy contract number

00544826

Policy instance

Insurance contract or identification number	00544826
Number of Individuals Covered	24
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $1,725
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $9,460
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

5980409

Policy instance

Insurance contract or identification number	5980409
Number of Individuals Covered	89
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $1,376
Total amount of fees paid to insurance company	USD $311
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,203
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NATIONAL GUARDIAN LIFE (National Association of Insurance Commissioners NAIC id number: 66583 )

Policy contract number

29349

Policy instance

Insurance contract or identification number	29349
Number of Individuals Covered	53
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $1,870
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $18,695
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

GLUG0B8BL

Policy instance

Insurance contract or identification number	GLUG0B8BL
Number of Individuals Covered	106
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $2,951
Total amount of fees paid to insurance company	USD $1,002
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $19,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	KMJ ENTERPRISES FIANNA HILLS LLC
Employer identification number (EIN):	820571556