JEFF BELZER'S HEALTH INSURANCE PLAN
|
2021
|
411385667
|
2022-10-12
|
JEFF BELZER'S TODD CHEVROLET, INC.
|
130
|
|
File |
View Page
|
Three-digit plan number (PN) |
501
|
Effective date of plan |
2021-07-01
|
Business code |
441110
|
Sponsor’s telephone number |
9524694444
|
Plan sponsor’s mailing address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Plan sponsor’s
address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Number of participants as of the end of the plan year
Active participants |
155 |
Retired or separated participants receiving
benefits |
2 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2022-10-12 |
Name of individual signing |
KYLE WESTON |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
JEFF BELZER'S LIFE/AD&D INSURANCE PLAN
|
2021
|
411385667
|
2022-10-12
|
JEFF BELZER'S TODD CHEVROLET, INC.
|
144
|
|
File |
View Page
|
Three-digit plan number (PN) |
503
|
Effective date of plan |
2021-07-01
|
Business code |
441110
|
Sponsor’s telephone number |
9524694444
|
Plan sponsor’s mailing address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Plan sponsor’s
address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Number of participants as of the end of the plan year
Active participants |
176 |
Retired or separated participants receiving
benefits |
3 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2022-10-12 |
Name of individual signing |
KYLE WESTON |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
JEFF BELZER'S DENTAL/VISION INSURANCE PLAN
|
2021
|
411385667
|
2022-10-12
|
JEFF BELZER'S TODD CHEVROLET, INC.
|
144
|
|
File |
View Page
|
Three-digit plan number (PN) |
502
|
Effective date of plan |
2021-07-01
|
Business code |
441110
|
Sponsor’s telephone number |
9524694444
|
Plan sponsor’s mailing address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Plan sponsor’s
address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Number of participants as of the end of the plan year
Active participants |
172 |
Retired or separated participants receiving
benefits |
3 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2022-10-12 |
Name of individual signing |
KYLE WESTON |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
JEFF BELZER'S LIFE/AD&D INSURANCE PLAN
|
2020
|
411385667
|
2021-09-28
|
JEFF BELZER'S TODD CHEVROLET, INC.
|
143
|
|
File |
View Page
|
Three-digit plan number (PN) |
503
|
Effective date of plan |
2020-07-01
|
Business code |
441110
|
Sponsor’s telephone number |
9524694444
|
Plan sponsor’s mailing address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Plan sponsor’s
address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Number of participants as of the end of the plan year
Active participants |
148 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2021-09-28 |
Name of individual signing |
KYLE WESTON |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
JEFF BELZER'S DENTAL INSURANCE PLAN
|
2020
|
411385667
|
2021-09-28
|
JEFF BELZER'S TODD CHEVROLET, INC.
|
133
|
|
File |
View Page
|
Three-digit plan number (PN) |
502
|
Effective date of plan |
2020-07-01
|
Business code |
441110
|
Sponsor’s telephone number |
9524694444
|
Plan sponsor’s mailing address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Plan sponsor’s
address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Number of participants as of the end of the plan year
Active participants |
139 |
Retired or separated participants receiving
benefits |
4 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2021-09-28 |
Name of individual signing |
KYLE WESTON |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
JEFF BELZER'S HEALTH INSURANCE PLAN
|
2020
|
411385667
|
2021-09-28
|
JEFF BELZER'S TODD CHEVROLET, INC.
|
123
|
|
File |
View Page
|
Three-digit plan number (PN) |
501
|
Effective date of plan |
2020-07-01
|
Business code |
441110
|
Sponsor’s telephone number |
9524694444
|
Plan sponsor’s mailing address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Plan sponsor’s
address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Number of participants as of the end of the plan year
Active participants |
130 |
Retired or separated participants receiving
benefits |
1 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2021-09-28 |
Name of individual signing |
KYLE WESTON |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
JEFF BELZER'S LIFE/AD&D INSURANCE PLAN
|
2019
|
411385667
|
2020-10-22
|
JEFF BELZER'S TODD CHEVROLET, INC.
|
146
|
|
File |
View Page
|
Three-digit plan number (PN) |
503
|
Effective date of plan |
2019-07-01
|
Business code |
441110
|
Sponsor’s telephone number |
9524694444
|
Plan sponsor’s mailing address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Plan sponsor’s
address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Number of participants as of the end of the plan year
Active participants |
134 |
Retired or separated participants receiving
benefits |
5 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2020-10-22 |
Name of individual signing |
KYLE WESTON |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
JEFF BELZER'S DENTAL INSURANCE PLAN
|
2019
|
411385667
|
2020-10-22
|
JEFF BELZER'S TODD CHEVROLET, INC.
|
136
|
|
File |
View Page
|
Three-digit plan number (PN) |
502
|
Effective date of plan |
2019-07-01
|
Business code |
441110
|
Sponsor’s telephone number |
9524694444
|
Plan sponsor’s mailing address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Plan sponsor’s
address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Number of participants as of the end of the plan year
Active participants |
126 |
Retired or separated participants receiving
benefits |
4 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2020-10-22 |
Name of individual signing |
KYLE WESTON |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
JEFF BELZER'S HEALTH INSURANCE PLAN
|
2019
|
411385667
|
2020-10-22
|
JEFF BELZER'S TODD CHEVROLET, INC.
|
130
|
|
File |
View Page
|
Three-digit plan number (PN) |
501
|
Effective date of plan |
2019-07-01
|
Business code |
441110
|
Sponsor’s telephone number |
9524694444
|
Plan sponsor’s mailing address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Plan sponsor’s
address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Number of participants as of the end of the plan year
Active participants |
123 |
Retired or separated participants receiving
benefits |
3 |
Other
retired or separated participants entitled to future benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2020-10-22 |
Name of individual signing |
KYLE WESTON |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
JEFF BELZER'S DENTAL INSURANCE PLAN
|
2018
|
411385667
|
2019-10-08
|
JEFF BELZER'S TODD CHEVROLET, INC.
|
131
|
|
File |
View Page
|
Three-digit plan number (PN) |
502
|
Effective date of plan |
2018-07-01
|
Business code |
441110
|
Sponsor’s telephone number |
9524697064
|
Plan sponsor’s mailing address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Plan sponsor’s
address |
21111 CEDAR AVENUE, LAKEVILLE, MN, 55044
|
Number of participants as of the end of the plan year
Active participants |
133 |
Retired or separated participants receiving
benefits |
0 |
Other
retired or separated participants entitled to future benefits |
0 |
Deceased participants
whose
beneficiaries are receiving or are entitled to receive benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2019-10-08 |
Name of individual signing |
KYLE WESTON |
Valid signature |
Filed with authorized/valid electronic signature |
|
|