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| Plan Name | SIMONA AMERICA, INC. MEDICAL PLAN |
| Plan identification number | 521 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | SIMONA AMERICA GROUP INC. |
| Employer identification number (EIN): | 134269250 |
| NAIC Classification: | 326100 |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 521 | 2018-01-01 | ANNA RINALDI | |||
| 521 | 2017-01-01 | ||||
| 521 | 2016-01-01 | MICHELLE MCGOUGH | |||
| 521 | 2015-01-01 | MICHELLE MCGOUGH |
| Measure | Date | Value |
|---|---|---|
| 2018: SIMONA AMERICA, INC. MEDICAL PLAN 2018 401k membership | ||
| Total participants, beginning-of-year | 2018-01-01 | 192 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 0 |
| Number of retired or separated participants receiving benefits | 2018-01-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2018-01-01 | 0 |
| Total of all active and inactive participants | 2018-01-01 | 0 |
| 2017: SIMONA AMERICA, INC. MEDICAL PLAN 2017 401k membership | ||
| Total participants, beginning-of-year | 2017-01-01 | 187 |
| Total number of active participants reported on line 7a of the Form 5500 | 2017-01-01 | 192 |
| Total of all active and inactive participants | 2017-01-01 | 192 |
| Total participants | 2017-01-01 | 192 |
| 2016: SIMONA AMERICA, INC. MEDICAL PLAN 2016 401k membership | ||
| Total participants, beginning-of-year | 2016-01-01 | 190 |
| Total number of active participants reported on line 7a of the Form 5500 | 2016-01-01 | 182 |
| Number of retired or separated participants receiving benefits | 2016-01-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2016-01-01 | 0 |
| Total of all active and inactive participants | 2016-01-01 | 187 |
| 2015: SIMONA AMERICA, INC. MEDICAL PLAN 2015 401k membership | ||
| Total participants, beginning-of-year | 2015-01-01 | 187 |
| Total number of active participants reported on line 7a of the Form 5500 | 2015-01-01 | 186 |
| Number of retired or separated participants receiving benefits | 2015-01-01 | 5 |
| Number of other retired or separated participants entitled to future benefits | 2015-01-01 | 0 |
| Total of all active and inactive participants | 2015-01-01 | 191 |
| 2018: SIMONA AMERICA, INC. MEDICAL PLAN 2018 form 5500 responses | ||
|---|---|---|
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | Yes |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2017: SIMONA AMERICA, INC. MEDICAL PLAN 2017 form 5500 responses | ||
| 2017-01-01 | Type of plan entity | Single employer plan |
| 2017-01-01 | Plan funding arrangement – Insurance | Yes |
| 2017-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2016: SIMONA AMERICA, INC. MEDICAL PLAN 2016 form 5500 responses | ||
| 2016-01-01 | Type of plan entity | Single employer plan |
| 2016-01-01 | Submission has been amended | No |
| 2016-01-01 | This submission is the final filing | No |
| 2016-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2016-01-01 | Plan is a collectively bargained plan | No |
| 2016-01-01 | Plan funding arrangement – Insurance | Yes |
| 2016-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2015: SIMONA AMERICA, INC. MEDICAL PLAN 2015 form 5500 responses | ||
| 2015-01-01 | Type of plan entity | Single employer plan |
| 2015-01-01 | First time form 5500 has been submitted | Yes |
| 2015-01-01 | Submission has been amended | No |
| 2015-01-01 | This submission is the final filing | No |
| 2015-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2015-01-01 | Plan is a collectively bargained plan | No |
| 2015-01-01 | Plan funding arrangement – Insurance | Yes |
| 2015-01-01 | Plan benefit arrangement – Insurance | Yes |
| AEGIS SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 33898 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | GP-PA0290 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 119947 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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| AEGIS SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 33898 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | GP-PA0290 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 119947 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 2 | ||||||||||||||||||||||||||||||||||||||||||||||||||||||||||
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