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| Plan Name | ROWE'S IGA LLC MEDICAL AND DENTAL PLAN |
| Plan identification number | 550 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | MASSY STORES (USA) LLC |
| Employer identification number (EIN): | 884339700 |
| NAIC Classification: | 445110 |
| NAIC Description: | Supermarkets and Other Grocery (except Convenience) Stores |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 550 | 2022-12-01 | KELLY WALSH | 2024-02-28 |
| Measure | Date | Value |
|---|---|---|
| 2022: ROWE'S IGA LLC MEDICAL AND DENTAL PLAN 2022 401k membership | ||
| Total participants, beginning-of-year | 2022-12-01 | 124 |
| Total number of active participants reported on line 7a of the Form 5500 | 2022-12-01 | 43 |
| Number of retired or separated participants receiving benefits | 2022-12-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2022-12-01 | 0 |
| Total of all active and inactive participants | 2022-12-01 | 43 |
| Number of employers contributing to the scheme | 2022-12-01 | 0 |
| 2022: ROWE'S IGA LLC MEDICAL AND DENTAL PLAN 2022 form 5500 responses | ||
|---|---|---|
| 2022-12-01 | Type of plan entity | Single employer plan |
| 2022-12-01 | First time form 5500 has been submitted | Yes |
| 2022-12-01 | Plan funding arrangement – Insurance | Yes |
| 2022-12-01 | Plan benefit arrangement – Insurance | Yes |
| BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 ) | |
| Policy contract number | 66769 |
| Policy instance | 1 |
| BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 95089 ) | |
| Policy contract number | 66769 |
| Policy instance | 2 |
| FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 ) | |
| Policy contract number | Y1352-6G4W92 |
| Policy instance | 3 |
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