401k Plan data: 48FORTY INTERMEDIATE HOLDINGS, INC. HEALTH AND WELFARE PLAN plan

48FORTY INTERMEDIATE HOLDINGS, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	48FORTY INTERMEDIATE HOLDINGS, INC. HEALTH AND WELFARE PLAN
Plan identification number	501

48FORTY INTERMEDIATE HOLDINGS, 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)

401k Sponsoring company profile

48FORTY INTERMEDIATE HOLDINGS, INC. has sponsored the creation of one or more 401k plans.

Company Name: 48FORTY INTERMEDIATE HOLDINGS, INC.

Employer identification number (EIN): 853786075

NAIC Classification: 339900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan 48FORTY INTERMEDIATE HOLDINGS, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 JEANNINE EDGREN 2023-07-24

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	JEANNINE EDGREN	2023-07-24

Plan Statistics for 48FORTY INTERMEDIATE HOLDINGS, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for 48FORTY INTERMEDIATE HOLDINGS, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2022: 48FORTY INTERMEDIATE HOLDINGS, INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 1,644
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 5,981
Number of retired or separated participants receiving benefits 2022-01-01 16
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 5,997

Measure	Date	Value
2022: 48FORTY INTERMEDIATE HOLDINGS, INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	1,644
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	5,981
Number of retired or separated participants receiving benefits	2022-01-01	16
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	5,997

Form 5500 Responses for 48FORTY INTERMEDIATE HOLDINGS, INC. HEALTH AND WELFARE PLAN

2022: 48FORTY INTERMEDIATE HOLDINGS, INC. HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

1034436/1034437

Policy instance

Insurance contract or identification number	1034436/1034437
Number of Individuals Covered	3552
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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 $140,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 81396 )

Policy contract number

21480

Policy instance

Insurance contract or identification number	21480
Number of Individuals Covered	3896
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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 $778,464
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

0236451

Policy instance

Insurance contract or identification number	0236451
Number of Individuals Covered	5981
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
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	ACCIDENTAL DEATH & DISMEMBERMENT
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 $1,288,331
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	48FORTY INTERMEDIATE HOLDINGS, INC.
Employer identification number (EIN):	853786075
NAIC Classification:	339900