401k Plan data: PERSEFONI AI INC HEALTH AND WELFARE PLAN plan

PERSEFONI AI INC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	PERSEFONI AI INC HEALTH AND WELFARE PLAN
Plan identification number	501

PERSEFONI AI INC HEALTH AND WELFARE 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 Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

PERSEFONI AI INC. has sponsored the creation of one or more 401k plans.

Company Name: PERSEFONI AI INC.

Employer identification number (EIN): 844382783

NAIC Classification: 541600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PERSEFONI AI INC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2024-04-01 COURTNEY REYNOLDS
501 2023-04-01
501 2023-04-01 COURTNEY REYNOLDS
501 2022-04-01 COURTNEY REYNOLDS 2023-12-29

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2024-04-01	COURTNEY REYNOLDS
501	2023-04-01
501	2023-04-01	COURTNEY REYNOLDS
501	2022-04-01	COURTNEY REYNOLDS	2023-12-29

Form 5500 Responses for PERSEFONI AI INC HEALTH AND WELFARE PLAN

2023: PERSEFONI AI INC HEALTH AND WELFARE PLAN 2023 form 5500 responses
2023-04-01	Type of plan entity	Single employer plan
2023-04-01	Submission has been amended	No
2023-04-01	This submission is the final filing	No
2023-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-04-01	Plan is a collectively bargained plan	No
2023-04-01	Plan funding arrangement – Insurance	Yes
2023-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-04-01	Plan benefit arrangement – Insurance	Yes
2023-04-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: PERSEFONI AI INC HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-04-01	Type of plan entity	Single employer plan
2022-04-01	First time form 5500 has been submitted	Yes
2022-04-01	Plan funding arrangement – Insurance	Yes
2022-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-04-01	Plan benefit arrangement – Insurance	Yes
2022-04-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

40148221

Policy instance

Insurance contract or identification number	40148221
Number of Individuals Covered	115
Insurance policy start date	2023-04-01
Insurance policy end date	2024-03-31
Total amount of commissions paid to insurance broker	USD $2,557
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $25,554
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

39221

Policy instance

Insurance contract or identification number	39221
Number of Individuals Covered	258
Insurance policy start date	2023-04-01
Insurance policy end date	2024-03-31
Total amount of commissions paid to insurance broker	USD $88,060
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $2,186,020
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0C3YF

Policy instance

Insurance contract or identification number	GLUG0C3YF
Number of Individuals Covered	184
Insurance policy start date	2023-04-01
Insurance policy end date	2024-03-31
Total amount of commissions paid to insurance broker	USD $20,699
Total amount of fees paid to insurance company	USD $5,291
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D, CRITICAL ILLNESS, ACCIDENT, AND EAP
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $139,195
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

1313

Policy instance

Insurance contract or identification number	1313
Number of Individuals Covered	262
Insurance policy start date	2023-04-01
Insurance policy end date	2024-03-31
Total amount of commissions paid to insurance broker	USD $16,611
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $157,068
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

39221

Policy instance

DELTA DENTAL OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53597 )

Policy contract number

1313

Policy instance

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

40148221

Policy instance

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

GLUG0C3YF

Policy instance

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Company Name:	PERSEFONI AI INC.
Employer identification number (EIN):	844382783
NAIC Classification:	541600