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| Plan Name | LORNA JANE USA INC. HEALTH AND WELFARE PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | LORNA JANE USA INC. |
| Employer identification number (EIN): | 990370263 |
| NAIC Classification: | 315240 |
| NAIC Description: | Women's, Girls', and Infants' Cut and Sew Apparel Manufacturing |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2019-12-01 | ||||
| 501 | 2016-12-01 | MEGAN KELLER | |||
| 501 | 2015-12-01 | SEAN HUNT |
| Measure | Date | Value |
|---|---|---|
| 2019: LORNA JANE USA INC. HEALTH AND WELFARE PLAN 2019 401k membership | ||
| Total participants, beginning-of-year | 2019-12-01 | 102 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-12-01 | 34 |
| Number of retired or separated participants receiving benefits | 2019-12-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2019-12-01 | 0 |
| Total of all active and inactive participants | 2019-12-01 | 36 |
| 2016: LORNA JANE USA INC. HEALTH AND WELFARE PLAN 2016 401k membership | ||
| Total participants, beginning-of-year | 2016-12-01 | 114 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-12-01 | 90 |
| Number of retired or separated participants receiving benefits | 2016-12-01 | 2 |
| Number of other retired or separated participants entitled to future benefits | 2016-12-01 | 0 |
| Total of all active and inactive participants | 2016-12-01 | 92 |
| 2015: LORNA JANE USA INC. HEALTH AND WELFARE PLAN 2015 401k membership | ||
| Total participants, beginning-of-year | 2015-12-01 | 113 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-12-01 | 97 |
| Number of retired or separated participants receiving benefits | 2015-12-01 | 1 |
| Number of other retired or separated participants entitled to future benefits | 2015-12-01 | 0 |
| Total of all active and inactive participants | 2015-12-01 | 98 |
| 2019: LORNA JANE USA INC. HEALTH AND WELFARE PLAN 2019 form 5500 responses | ||
|---|---|---|
| 2019-12-01 | Type of plan entity | Single employer plan |
| 2019-12-01 | Submission has been amended | No |
| 2019-12-01 | This submission is the final filing | No |
| 2019-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-12-01 | Plan is a collectively bargained plan | No |
| 2019-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2019-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: LORNA JANE USA INC. HEALTH AND WELFARE PLAN 2016 form 5500 responses | ||
| 2016-12-01 | Type of plan entity | Single employer plan |
| 2016-12-01 | Submission has been amended | No |
| 2016-12-01 | This submission is the final filing | No |
| 2016-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-12-01 | Plan is a collectively bargained plan | No |
| 2016-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2016-12-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: LORNA JANE USA INC. HEALTH AND WELFARE PLAN 2015 form 5500 responses | ||
| 2015-12-01 | Type of plan entity | Single employer plan |
| 2015-12-01 | First time form 5500 has been submitted | Yes |
| 2015-12-01 | Submission has been amended | No |
| 2015-12-01 | This submission is the final filing | No |
| 2015-12-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-12-01 | Plan is a collectively bargained plan | No |
| 2015-12-01 | Plan funding arrangement – General assets of the sponsor | Yes |
| 2015-12-01 | Plan benefit arrangement – Insurance | Yes |
| ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62825 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 278981 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| BLUE CROSS OF CALIFORNIA (National Association of Insurance Commissioners NAIC id number: 00000 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 278981 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 9907 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 3 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 232841 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 4 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| PACIFIC GUARDIAN LIFE INSURANCE COMPANY, LTD. (National Association of Insurance Commissioners NAIC id number: 64343 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 54594 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 5 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 605034 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 6 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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