401k Plan data: CHI AUTOMART INC HEALTH AND WELFARE PLAN plan

CHI AUTOMART INC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	CHI AUTOMART INC HEALTH AND WELFARE PLAN
Plan identification number	501

CHI AUTOMART 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 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

CHI AUTO MART, INC. has sponsored the creation of one or more 401k plans.

Company Name: CHI AUTO MART, INC.

Employer identification number (EIN): 954260437

NAIC Classification: 441110
NAIC Description: New Car Dealers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CHI AUTOMART INC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2018-04-01

Plan Statistics for CHI AUTOMART INC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for CHI AUTOMART INC HEALTH AND WELFARE PLAN

Measure Date Value
2018: CHI AUTOMART INC HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-04-01 153
Total number of active participants reported on line 7a of the Form 5500 2018-04-01 63
Number of retired or separated participants receiving benefits 2018-04-01 3
Number of other retired or separated participants entitled to future benefits 2018-04-01 0
Total of all active and inactive participants 2018-04-01 66

Measure	Date	Value
2018: CHI AUTOMART INC HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-04-01	153
Total number of active participants reported on line 7a of the Form 5500	2018-04-01	63
Number of retired or separated participants receiving benefits	2018-04-01	3
Number of other retired or separated participants entitled to future benefits	2018-04-01	0
Total of all active and inactive participants	2018-04-01	66

Form 5500 Responses for CHI AUTOMART INC HEALTH AND WELFARE PLAN

2018: CHI AUTOMART INC HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-04-01	Type of plan entity	Single employer plan
2018-04-01	Submission has been amended	No
2018-04-01	This submission is the final filing	No
2018-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-04-01	Plan is a collectively bargained plan	No
2018-04-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

497070-1

Policy instance

Insurance contract or identification number	497070-1
Number of Individuals Covered	12
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $625
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	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 $5,769
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $571
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

232558

Policy instance

Insurance contract or identification number	232558
Number of Individuals Covered	53
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $25,737
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	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 $411,701
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,776
Insurance broker organization code?	3

AMERICAN FIDELITY ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 60410 )

Policy contract number

35578

Policy instance

Insurance contract or identification number	35578
Number of Individuals Covered	1
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $-673
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	No
Life Insurance Welfare Benefit	No
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 $19,297
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $965
Insurance broker organization code?	3

AMERICAN HERITAGE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60534 )

Policy contract number

93962

Policy instance

Insurance contract or identification number	93962
Number of Individuals Covered	63
Insurance policy start date	2018-04-01
Insurance policy end date	2019-03-31
Total amount of commissions paid to insurance broker	USD $7,577
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	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	CANCER/ACCIDENT/CRITICAL ILLNESS
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 $34,132
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,541
Insurance broker organization code?	3

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Company Name:	CHI AUTO MART, INC.
Employer identification number (EIN):	954260437
NAIC Classification:	441110
NAIC Description:	New Car Dealers