401k Plan data: KOMLINE-SANDERSON HEALTH & WELFARE PLAN plan

KOMLINE-SANDERSON HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	KOMLINE-SANDERSON HEALTH & WELFARE PLAN
Plan identification number	501

KOMLINE-SANDERSON HEALTH & 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 Other welfare benefit cover

401k Sponsoring company profile

KOMLINE-SANDERSON has sponsored the creation of one or more 401k plans.

Company Name: KOMLINE-SANDERSON

Employer identification number (EIN): 862362357

NAIC Classification: 333310

Form 5500 Filing Information

Submission information for form 5500 for 401k plan KOMLINE-SANDERSON HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-02-01

Plan Statistics for KOMLINE-SANDERSON HEALTH & WELFARE PLAN

401k plan membership statisitcs for KOMLINE-SANDERSON HEALTH & WELFARE PLAN

Measure Date Value
2022: KOMLINE-SANDERSON HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-02-01 251
Total number of active participants reported on line 7a of the Form 5500 2022-02-01 278
Number of retired or separated participants receiving benefits 2022-02-01 1
Number of other retired or separated participants entitled to future benefits 2022-02-01 0
Total of all active and inactive participants 2022-02-01 279

Measure	Date	Value
2022: KOMLINE-SANDERSON HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-02-01	251
Total number of active participants reported on line 7a of the Form 5500	2022-02-01	278
Number of retired or separated participants receiving benefits	2022-02-01	1
Number of other retired or separated participants entitled to future benefits	2022-02-01	0
Total of all active and inactive participants	2022-02-01	279

Form 5500 Responses for KOMLINE-SANDERSON HEALTH & WELFARE PLAN

2022: KOMLINE-SANDERSON HEALTH & WELFARE PLAN 2022 form 5500 responses
2022-02-01	Type of plan entity	Single employer plan
2022-02-01	First time form 5500 has been submitted	Yes
2022-02-01	Submission has been amended	No
2022-02-01	This submission is the final filing	No
2022-02-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2022-02-01	Plan is a collectively bargained plan	No
2022-02-01	Plan funding arrangement – Insurance	Yes
2022-02-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-02-01	Plan benefit arrangement – Insurance	Yes
2022-02-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

STARMOUNT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68985 )

Policy contract number

712298

Policy instance

Insurance contract or identification number	712298
Number of Individuals Covered	284
Insurance policy start date	2022-02-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $18,299
Total amount of fees paid to insurance company	USD $7,319
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	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 $182,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,299
Amount paid for insurance broker fees	7319
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

712297

Policy instance

Insurance contract or identification number	712297
Number of Individuals Covered	105
Insurance policy start date	2022-02-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,069
Total amount of fees paid to insurance company	USD $1,227
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	No
Long Term Disability Insurance Welfare Benefit	No
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 $30,690
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,069
Amount paid for insurance broker fees	1227
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

712296

Policy instance

Insurance contract or identification number	712296
Number of Individuals Covered	305
Insurance policy start date	2022-02-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $22,140
Total amount of fees paid to insurance company	USD $8,856
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	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 $221,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,140
Amount paid for insurance broker fees	8856
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0176590

Policy instance

Insurance contract or identification number	0176590
Number of Individuals Covered	491
Insurance policy start date	2022-02-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $101,436
Total amount of fees paid to insurance company	USD $14,650
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 $3,172,509
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $101,436
Amount paid for insurance broker fees	14650
Additional information about fees paid to insurance broker	2022 Q1 GROW WITH US NEW BUSINESS INCENTIVE RISK, 2022 Q1 SIGNATURE MEDICAL NEW BUSINESS RISK
Insurance broker organization code?	3

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Company Name:	KOMLINE-SANDERSON
Employer identification number (EIN):	862362357
NAIC Classification:	333310