401k Plan data: AL LARSON BOAT SHOP HEALTH AND WELFARE BENEFITS plan

AL LARSON BOAT SHOP HEALTH AND WELFARE BENEFITS 401k Plan overview

Plan Name	AL LARSON BOAT SHOP HEALTH AND WELFARE BENEFITS
Plan identification number	501

AL LARSON BOAT SHOP HEALTH AND WELFARE BENEFITS Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

AL LARSON BOAT SHOP INC. has sponsored the creation of one or more 401k plans.

Company Name: AL LARSON BOAT SHOP INC.

Employer identification number (EIN): 950923340

NAIC Classification: 811310
NAIC Description: Commercial and Industrial Machinery and Equipment (except Automotive and Electronic) Repair and Maintenance

Form 5500 Filing Information

Submission information for form 5500 for 401k plan AL LARSON BOAT SHOP HEALTH AND WELFARE BENEFITS

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-07-01

Plan Statistics for AL LARSON BOAT SHOP HEALTH AND WELFARE BENEFITS

401k plan membership statisitcs for AL LARSON BOAT SHOP HEALTH AND WELFARE BENEFITS

Measure Date Value
2021: AL LARSON BOAT SHOP HEALTH AND WELFARE BENEFITS 2021 401k membership
Total participants, beginning-of-year 2021-07-01 142
Total number of active participants reported on line 7a of the Form 5500 2021-07-01 64
Number of retired or separated participants receiving benefits 2021-07-01 0
Number of other retired or separated participants entitled to future benefits 2021-07-01 0
Total of all active and inactive participants 2021-07-01 64

Measure	Date	Value
2021: AL LARSON BOAT SHOP HEALTH AND WELFARE BENEFITS 2021 401k membership
Total participants, beginning-of-year	2021-07-01	142
Total number of active participants reported on line 7a of the Form 5500	2021-07-01	64
Number of retired or separated participants receiving benefits	2021-07-01	0
Number of other retired or separated participants entitled to future benefits	2021-07-01	0
Total of all active and inactive participants	2021-07-01	64

Form 5500 Responses for AL LARSON BOAT SHOP HEALTH AND WELFARE BENEFITS

2021: AL LARSON BOAT SHOP HEALTH AND WELFARE BENEFITS 2021 form 5500 responses
2021-07-01	Type of plan entity	Single employer plan
2021-07-01	First time form 5500 has been submitted	Yes
2021-07-01	Submission has been amended	No
2021-07-01	This submission is the final filing	No
2021-07-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-07-01	Plan is a collectively bargained plan	No
2021-07-01	Plan funding arrangement – Insurance	Yes
2021-07-01	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

W0083409

Policy instance

Insurance contract or identification number	W0083409
Number of Individuals Covered	135
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $65,316
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 $891,073
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	51246
Additional information about fees paid to insurance broker	PRODUCER SERVICE FEES
Insurance broker organization code?	3

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00392290

Policy instance

Insurance contract or identification number	00392290
Number of Individuals Covered	30
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $4,137
Total amount of fees paid to insurance company	USD $1,359
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 $24,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,920
Amount paid for insurance broker fees	1359
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

12067539

Policy instance

Insurance contract or identification number	12067539
Number of Individuals Covered	25
Insurance policy start date	2021-07-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $528
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 $5,644
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $528
Insurance broker organization code?	3

Potentially related plans

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Company Name:	AL LARSON BOAT SHOP INC.
Employer identification number (EIN):	950923340
NAIC Classification:	811310
NAIC Description:	Commercial and Industrial Machinery and Equipment (except Automotive and Electronic) Repair and Maintenance