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| Plan Name | JAMES W. MELLERT, DDS, INC. WELFARE BENEFIT TRUST |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | JAMES W. MELLERT, DDS, APC |
| Employer identification number (EIN): | 330056789 |
| NAIC Classification: | 621210 |
| NAIC Description: | Offices of Dentists |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2012-12-28 | JAMES MELLERT | 2014-03-18 | JAMES MELLERT | 2014-03-18 |
| 501 | 2011-12-28 | JAMES MELLERT | |||
| 501 | 2009-12-28 | JAMES MELLERT |
| Measure | Date | Value |
|---|---|---|
| 2011: JAMES W. MELLERT, DDS, INC. WELFARE BENEFIT TRUST 2011 401k membership | ||
| Total participants, beginning-of-year | 2011-12-28 | 11 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-12-28 | 11 |
| Number of retired or separated participants receiving benefits | 2011-12-28 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-12-28 | 0 |
| Total of all active and inactive participants | 2011-12-28 | 11 |
| 2009: JAMES W. MELLERT, DDS, INC. WELFARE BENEFIT TRUST 2009 401k membership | ||
| Total participants, beginning-of-year | 2009-12-28 | 7 |
| Total number of active participants reported on line 7a of the Form 5500 | 2009-12-28 | 7 |
| Number of retired or separated participants receiving benefits | 2009-12-28 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2009-12-28 | 0 |
| Total of all active and inactive participants | 2009-12-28 | 7 |
| Measure | Date | Value |
|---|---|---|
| 2012 : JAMES W. MELLERT, DDS, INC. WELFARE BENEFIT TRUST 2012 401k financial data | ||
| Total plan liabilities at end of year | 2012-12-27 | $754,335 |
| Total plan liabilities at beginning of year | 2012-12-27 | $700,617 |
| Total income from all sources | 2012-12-27 | $10,531 |
| Expenses. Total of all expenses incurred | 2012-12-27 | $10,531 |
| Total plan assets at end of year | 2012-12-27 | $754,335 |
| Total plan assets at beginning of year | 2012-12-27 | $700,617 |
| Expenses. Other expenses not covered elsewhere | 2012-12-27 | $10,531 |
| Other income received | 2012-12-27 | $72 |
| Net income (gross income less expenses) | 2012-12-27 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2012-12-27 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2012-12-27 | $0 |
| Total contributions received or receivable from employer(s) | 2012-12-27 | $10,459 |
| 2011 : JAMES W. MELLERT, DDS, INC. WELFARE BENEFIT TRUST 2011 401k financial data | ||
| Total plan liabilities at end of year | 2011-12-27 | $700,617 |
| Total plan liabilities at beginning of year | 2011-12-27 | $647,774 |
| Total income from all sources | 2011-12-27 | $6,189 |
| Expenses. Total of all expenses incurred | 2011-12-27 | $6,189 |
| Total plan assets at end of year | 2011-12-27 | $700,617 |
| Total plan assets at beginning of year | 2011-12-27 | $647,774 |
| Expenses. Other expenses not covered elsewhere | 2011-12-27 | $4,649 |
| Net income (gross income less expenses) | 2011-12-27 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2011-12-27 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2011-12-27 | $0 |
| Total contributions received or receivable from employer(s) | 2011-12-27 | $6,189 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2011-12-27 | $1,540 |
| 2011: JAMES W. MELLERT, DDS, INC. WELFARE BENEFIT TRUST 2011 form 5500 responses | ||
|---|---|---|
| 2011-12-28 | Type of plan entity | Single employer plan |
| 2011-12-28 | Submission has been amended | No |
| 2011-12-28 | This submission is the final filing | No |
| 2011-12-28 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-12-28 | Plan is a collectively bargained plan | No |
| 2011-12-28 | Plan funding arrangement – Insurance | Yes |
| 2011-12-28 | Plan funding arrangement – Trust | Yes |
| 2011-12-28 | Plan benefit arrangement – Insurance | Yes |
| 2011-12-28 | Plan benefit arrangement - Trust | Yes |
| 2009: JAMES W. MELLERT, DDS, INC. WELFARE BENEFIT TRUST 2009 form 5500 responses | ||
| 2009-12-28 | Type of plan entity | Single employer plan |
| 2009-12-28 | Submission has been amended | No |
| 2009-12-28 | This submission is the final filing | No |
| 2009-12-28 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2009-12-28 | Plan is a collectively bargained plan | No |
| 2009-12-28 | Plan funding arrangement – Insurance | Yes |
| 2009-12-28 | Plan funding arrangement – Trust | Yes |
| 2009-12-28 | Plan benefit arrangement – Insurance | Yes |
| 2009-12-28 | Plan benefit arrangement - Trust | Yes |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | TL-242-9067 | ||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||
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| PACIFIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67466 ) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | VF51598710 | ||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 9067 | ||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||
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| PACIFIC LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 67466 ) | |||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | VF51598710 | ||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||
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