401k Plan data: SIMONA AMERICA, INC. VISION PLAN plan

SIMONA AMERICA, INC. VISION PLAN 401k Plan overview

Plan Name	SIMONA AMERICA, INC. VISION PLAN
Plan identification number	525

SIMONA AMERICA, INC. VISION PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Vision

401k Sponsoring company profile

SIMONA AMERICA GROUP INC. has sponsored the creation of one or more 401k plans.

Company Name: SIMONA AMERICA GROUP INC.

Employer identification number (EIN): 134269250

NAIC Classification: 326100

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SIMONA AMERICA, INC. VISION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
525 2018-01-01 ANNA RINALDI
525 2017-01-01
525 2016-01-01 MICHELLE MCGOUGH
525 2015-01-01 MICHELLE MCGOUGH

Plan Statistics for SIMONA AMERICA, INC. VISION PLAN

401k plan membership statisitcs for SIMONA AMERICA, INC. VISION PLAN

Measure Date Value
2018: SIMONA AMERICA, INC. VISION PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 82
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. VISION PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 180
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 82
Total of all active and inactive participants 2017-01-01 82
Total participants 2017-01-01 82
2016: SIMONA AMERICA, INC. VISION PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 172
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 180
Number of retired or separated participants receiving benefits 2016-01-01 1
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 181
2015: SIMONA AMERICA, INC. VISION PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 110
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 107
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 107

Measure	Date	Value
2018: SIMONA AMERICA, INC. VISION PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	82
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. VISION PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	180
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	82
Total of all active and inactive participants	2017-01-01	82
Total participants	2017-01-01	82
2016: SIMONA AMERICA, INC. VISION PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	172
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	180
Number of retired or separated participants receiving benefits	2016-01-01	1
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	181
2015: SIMONA AMERICA, INC. VISION PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	110
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	107
Number of retired or separated participants receiving benefits	2015-01-01	0
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	107

Form 5500 Responses for SIMONA AMERICA, INC. VISION PLAN

2018: SIMONA AMERICA, INC. VISION 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. VISION 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. VISION 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. VISION 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

Insurance Providers Used on plan

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10156091001

Policy instance

Insurance contract or identification number	10156091001
Number of Individuals Covered	184
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $1,240
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	Yes
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 $13,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,240
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	NONE
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KM05934379

Policy instance

Insurance contract or identification number	KM05934379
Number of Individuals Covered	291
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $490
Total amount of fees paid to insurance company	USD $326
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $8,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $245
Amount paid for insurance broker fees	277
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	BB&T INSURANCE SERVICES, INC

HIGHMARK BLUE SHIELD (National Association of Insurance Commissioners NAIC id number: 54771 )

Policy contract number

119947

Policy instance

Insurance contract or identification number	119947
Number of Individuals Covered	188
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,312
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

VISION BENEFITS OF AMERICA (National Association of Insurance Commissioners NAIC id number: 53953 )

Policy contract number

2913

Policy instance

Insurance contract or identification number	2913
Number of Individuals Covered	98
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $338
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $193
Insurance broker organization code?	3
Insurance broker name	HARRISON BENEFIT SERVICES, LLC

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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
525	2018-01-01	ANNA RINALDI
525	2017-01-01
525	2016-01-01	MICHELLE MCGOUGH
525	2015-01-01	MICHELLE MCGOUGH