401k Plan data: INNOVATION LINE HEALTH AND WELFARE BENEFITS PROGRAM plan

INNOVATION LINE HEALTH AND WELFARE BENEFITS PROGRAM 401k Plan overview

Plan Name	INNOVATION LINE HEALTH AND WELFARE BENEFITS PROGRAM
Plan identification number	501

INNOVATION LINE HEALTH AND WELFARE BENEFITS PROGRAM Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision

401k Sponsoring company profile

INNOVATION SPECIALTIES has sponsored the creation of one or more 401k plans.

Company Name: INNOVATION SPECIALTIES

Employer identification number (EIN): 953345974

NAIC Classification: 423990
NAIC Description: Other Miscellaneous Durable Goods Merchant Wholesalers

Additional information about INNOVATION SPECIALTIES

Jurisdiction of Incorporation: California Department of State

Incorporation Date:

Company Identification Number: C0863936

More information about INNOVATION SPECIALTIES

Form 5500 Filing Information

Submission information for form 5500 for 401k plan INNOVATION LINE HEALTH AND WELFARE BENEFITS PROGRAM

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-10-01

Plan Statistics for INNOVATION LINE HEALTH AND WELFARE BENEFITS PROGRAM

401k plan membership statisitcs for INNOVATION LINE HEALTH AND WELFARE BENEFITS PROGRAM

Measure Date Value
2021: INNOVATION LINE HEALTH AND WELFARE BENEFITS PROGRAM 2021 401k membership
Total participants, beginning-of-year 2021-10-01 169
Total number of active participants reported on line 7a of the Form 5500 2021-10-01 155
Number of retired or separated participants receiving benefits 2021-10-01 0
Number of other retired or separated participants entitled to future benefits 2021-10-01 0
Total of all active and inactive participants 2021-10-01 155

Measure	Date	Value
2021: INNOVATION LINE HEALTH AND WELFARE BENEFITS PROGRAM 2021 401k membership
Total participants, beginning-of-year	2021-10-01	169
Total number of active participants reported on line 7a of the Form 5500	2021-10-01	155
Number of retired or separated participants receiving benefits	2021-10-01	0
Number of other retired or separated participants entitled to future benefits	2021-10-01	0
Total of all active and inactive participants	2021-10-01	155

Form 5500 Responses for INNOVATION LINE HEALTH AND WELFARE BENEFITS PROGRAM

2021: INNOVATION LINE HEALTH AND WELFARE BENEFITS PROGRAM 2021 form 5500 responses
2021-10-01	Type of plan entity	Single employer plan
2021-10-01	First time form 5500 has been submitted	Yes
2021-10-01	Submission has been amended	No
2021-10-01	This submission is the final filing	No
2021-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-10-01	Plan is a collectively bargained plan	No
2021-10-01	Plan funding arrangement – Insurance	Yes
2021-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

L03676

Policy instance

Insurance contract or identification number	L03676
Number of Individuals Covered	58
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $24,294
Total amount of fees paid to insurance company	USD $5,469
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 $481,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,294
Amount paid for insurance broker fees	5469
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 )

Policy contract number

L03676

Policy instance

Insurance contract or identification number	L03676
Number of Individuals Covered	155
Insurance policy start date	2021-10-01
Insurance policy end date	2022-09-30
Total amount of commissions paid to insurance broker	USD $5,667
Total amount of fees paid to insurance company	USD $1,276
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	Yes
Vision Insurance Welfare Benefit	Yes
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 $112,240
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,667
Amount paid for insurance broker fees	1276
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3

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Company Name:	INNOVATION SPECIALTIES
Employer identification number (EIN):	953345974
NAIC Classification:	423990
NAIC Description:	Other Miscellaneous Durable Goods Merchant Wholesalers

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	C0863936