401k Plan data: DEVIATION GAMES LLC HEALTH PLAN plan

DEVIATION GAMES LLC HEALTH PLAN 401k Plan overview

Plan Name	DEVIATION GAMES LLC HEALTH PLAN
Plan identification number	501

DEVIATION GAMES LLC HEALTH PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

DEVIATION GAMES has sponsored the creation of one or more 401k plans.

Company Name: DEVIATION GAMES

Employer identification number (EIN): 843010812

NAIC Classification: 334110

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DEVIATION GAMES LLC HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 KRISTE STULL 2023-10-10

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	KRISTE STULL	2023-10-10

Plan Statistics for DEVIATION GAMES LLC HEALTH PLAN

401k plan membership statisitcs for DEVIATION GAMES LLC HEALTH PLAN

Measure Date Value
2022: DEVIATION GAMES LLC HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 121
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 121
Number of employers contributing to the scheme 2022-01-01 0

Measure	Date	Value
2022: DEVIATION GAMES LLC HEALTH PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	121
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	121
Number of employers contributing to the scheme	2022-01-01	0

Form 5500 Responses for DEVIATION GAMES LLC HEALTH PLAN

2022: DEVIATION GAMES LLC HEALTH PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	First time form 5500 has been submitted	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0109124

Policy instance

Insurance contract or identification number	W0109124
Number of Individuals Covered	194
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $839
Total amount of fees paid to insurance company	USD $62,942
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,074,925
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	62942
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES, BONUS OVERRIDE
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

352637

Policy instance

Insurance contract or identification number	352637
Number of Individuals Covered	38
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $10,529
Total amount of fees paid to insurance company	USD $109
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $195,205
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,836
Amount paid for insurance broker fees	109
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

DELTA DENTAL OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

21744

Policy instance

Insurance contract or identification number	21744
Number of Individuals Covered	235
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $14,095
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $140,951
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $14,095
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

1133503

Policy instance

Insurance contract or identification number	1133503
Number of Individuals Covered	225
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $8,095
Total amount of fees paid to insurance company	USD $1,758
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT
Welfare Benefit Premiums Paid to Carrier	USD $54,120
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,095
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Additional information about fees paid to insurance broker	BONUS

Potentially related plans

DEVIATION GAMES LLC 401(K) PLAN [EIN = 844620673]

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Company Name:	DEVIATION GAMES
Employer identification number (EIN):	843010812
NAIC Classification:	334110