401k Plan data: GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL plan

GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL 401k Plan overview

Plan Name	GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL
Plan identification number	501

GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental

401k Sponsoring company profile

GRAFF DIAMONDS (NY) INC. has sponsored the creation of one or more 401k plans.

Company Name: GRAFF DIAMONDS (NY) INC.

Employer identification number (EIN): 134127445

NAIC Classification: 448310
NAIC Description: Jewelry Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2014-01-01
501 2014-01-01 PAOLO DE NICHILO
501 2013-01-01 PAOLO DE NICHILO PAOLO DE NICHILO 2014-07-23

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
501	2014-01-01
501	2014-01-01	PAOLO DE NICHILO
501	2013-01-01	PAOLO DE NICHILO	PAOLO DE NICHILO	2014-07-23

Plan Statistics for GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL

401k plan membership statisitcs for GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL

Measure Date Value
2014: GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL 2014 401k membership
Total participants, beginning-of-year 2014-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 0
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 0
2013: GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL 2013 401k membership
Total participants, beginning-of-year 2013-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 115
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 115

Measure	Date	Value
2014: GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL 2014 401k membership
Total participants, beginning-of-year	2014-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	0
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	0
2013: GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL 2013 401k membership
Total participants, beginning-of-year	2013-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	115
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	115

Form 5500 Responses for GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL

2014: GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	Yes
2014-01-01	This submission is the final filing	Yes
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: GRAFF DIAMONDS (NY) INC. MEDICAL AND DENTAL 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	First time form 5500 has been submitted	Yes
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3335458

Policy instance

Insurance contract or identification number	3335458
Number of Individuals Covered	113
Insurance policy start date	2013-12-01
Insurance policy end date	2014-11-30
Total amount of commissions paid to insurance broker	USD $70,757
Total amount of fees paid to insurance company	USD $34,354
Are there contracts with allocated funds for individual policies?	No
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	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 $1,616,214
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $70,757
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	EMERSON REID AND COMPANY, INC.

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3335458

Policy instance

Insurance contract or identification number	3335458
Number of Individuals Covered	107
Insurance policy start date	2012-12-01
Insurance policy end date	2013-11-30
Total amount of commissions paid to insurance broker	USD $67,667
Total amount of fees paid to insurance company	USD $37,664
Are there contracts with allocated funds for individual policies?	No
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	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 $1,542,488
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $67,667
Insurance broker organization code?	3
Amount paid for insurance broker fees	37664
Additional information about fees paid to insurance broker	GENERAL AGENT PAYMENTS
Insurance broker name	EMERSON REID AND COMPANY, INC.

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Company Name:	GRAFF DIAMONDS (NY) INC.
Employer identification number (EIN):	134127445
NAIC Classification:	448310
NAIC Description:	Jewelry Stores