BLACKFOX, LLC GROUP MEDICAL, LIFE AND DISABILITY PLAN
|
2009
|
261857564
|
2011-01-12
|
BLACKFOX, LLC
|
227
|
|
File |
View Page
|
Three-digit plan number (PN) |
502
|
Effective date of plan |
1994-04-01
|
Business code |
551112
|
Sponsor’s telephone number |
3034858055
|
Plan sponsor’s mailing address |
P.O. BOX 209, HYGIENE, CO, 80533
|
Plan sponsor’s
address |
11797 N. 75TH STREET, LONGMONT, CO, 80503
|
Plan administrator’s name and address
Administrator’s EIN |
261857564 |
Plan administrator’s name |
BLACKFOX, LLC |
Plan administrator’s
address |
P.O. BOX 209, HYGIENE, CO, 80533 |
Administrator’s telephone number |
3034858055 |
Number of participants as of the end of the plan year
Active participants |
0 |
Retired or separated participants receiving
benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2011-01-12 |
Name of individual signing |
BRIAN HEPP |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
BLACKFOX, LLC GROUP VISION CARE PLAN
|
2009
|
261857564
|
2011-01-12
|
BLACKFOX, LLC
|
218
|
|
File |
View Page
|
Three-digit plan number (PN) |
504
|
Effective date of plan |
1996-04-01
|
Business code |
551112
|
Sponsor’s telephone number |
3034858055
|
Plan sponsor’s mailing address |
P.O. BOX 209, HYGIENE, CO, 80533
|
Plan sponsor’s
address |
11797 N. 75TH STREET, LONGMONT, CO, 80503
|
Plan administrator’s name and address
Administrator’s EIN |
261857564 |
Plan administrator’s name |
BLACKFOX, LLC |
Plan administrator’s
address |
P.O. BOX 209, HYGIENE, CO, 80533 |
Administrator’s telephone number |
3034858055 |
Number of participants as of the end of the plan year
Active participants |
0 |
Retired or separated participants receiving
benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2011-01-12 |
Name of individual signing |
BRIAN HEPP |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
BLACKFOX, LLC VOLUNTARY DENTAL PLAN
|
2009
|
261857564
|
2011-01-12
|
BLACKFOX, LLC
|
112
|
|
File |
View Page
|
Three-digit plan number (PN) |
503
|
Effective date of plan |
1994-04-01
|
Business code |
551112
|
Sponsor’s telephone number |
3034858055
|
Plan sponsor’s mailing address |
P.O. BOX 209, HYGIENE, CO, 80533
|
Plan sponsor’s
address |
11797 N. 75TH STREET, LONGMONT, CO, 80503
|
Plan administrator’s name and address
Administrator’s EIN |
261857564 |
Plan administrator’s name |
BLACKFOX, LLC |
Plan administrator’s
address |
P.O. BOX 209, HYGIENE, CO, 80533 |
Administrator’s telephone number |
3034858055 |
Number of participants as of the end of the plan year
Active participants |
0 |
Retired or separated participants receiving
benefits |
0 |
Signature of
Role |
Plan administrator |
Date |
2011-01-12 |
Name of individual signing |
BRIAN HEPP |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
BLACKFOX, LLC GROUP VISION CARE PLAN
|
2009
|
261857564
|
2011-01-04
|
BLACKFOX, LLC
|
218
|
|
Three-digit plan number (PN) |
504
|
Effective date of plan |
1996-04-01
|
Business code |
551112
|
Sponsor’s telephone number |
3034858055
|
Plan sponsor’s mailing address |
P.O. BOX 209, HYGIENE, CO, 80533
|
Plan sponsor’s
address |
11797 N. 75TH STREET, LONGMONT, CO, 80503
|
Plan administrator’s name and address
Administrator’s EIN |
261857564 |
Plan administrator’s name |
BLACKFOX, LLC |
Plan administrator’s
address |
P.O. BOX 209, HYGIENE, CO, 80533 |
Administrator’s telephone number |
3034858055 |
Number of participants as of the end of the plan year
Active participants |
0 |
Retired or separated participants receiving
benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2010-12-28 |
Name of individual signing |
BRIAN HEPP |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
BLACKFOX, LLC VOLUNTARY DENTAL PLAN
|
2009
|
261857564
|
2011-01-04
|
BLACKFOX, LLC
|
112
|
|
Three-digit plan number (PN) |
503
|
Effective date of plan |
1994-04-01
|
Business code |
551112
|
Sponsor’s telephone number |
3034858055
|
Plan sponsor’s mailing address |
P.O. BOX 209, HYGIENE, CO, 80533
|
Plan sponsor’s
address |
11797 N. 75TH STREET, LONGMONT, CO, 80503
|
Plan administrator’s name and address
Administrator’s EIN |
261857564 |
Plan administrator’s name |
BLACKFOX, LLC |
Plan administrator’s
address |
P.O. BOX 209, HYGIENE, CO, 80533 |
Administrator’s telephone number |
3034858055 |
Number of participants as of the end of the plan year
Active participants |
0 |
Retired or separated participants receiving
benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2010-12-28 |
Name of individual signing |
BRIAN HEPP |
Valid signature |
Filed with authorized/valid electronic signature |
|
|
BLACKFOX, LLC GROUP MEDICAL, LIFE AND DISABILITY PLAN
|
2009
|
261857564
|
2011-01-04
|
BLACKFOX, LLC
|
227
|
|
Three-digit plan number (PN) |
502
|
Effective date of plan |
1994-04-01
|
Business code |
551112
|
Sponsor’s telephone number |
3034858055
|
Plan sponsor’s mailing address |
P.O. BOX 209, HYGIENE, CO, 80533
|
Plan sponsor’s
address |
11797 N. 75TH STREET, LONGMONT, CO, 80503
|
Plan administrator’s name and address
Administrator’s EIN |
261857564 |
Plan administrator’s name |
BLACKFOX, LLC |
Plan administrator’s
address |
P.O. BOX 209, HYGIENE, CO, 80533 |
Administrator’s telephone number |
3034858055 |
Number of participants as of the end of the plan year
Active participants |
0 |
Retired or separated participants receiving
benefits |
0 |
Signature of
Role |
Employer/plan sponsor |
Date |
2010-12-28 |
Name of individual signing |
BRIAN HEPP |
Valid signature |
Filed with authorized/valid electronic signature |
|
|