401k Plan data: H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN plan

H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN
Plan identification number	501

H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Temporary disability (accident and sickness) Long-term disability cover

401k Sponsoring company profile

H-O-H WATER TECHNOLOGY, INC has sponsored the creation of one or more 401k plans.

Company Name: H-O-H WATER TECHNOLOGY, INC

Employer identification number (EIN): 362663459

NAIC Classification: 541990
NAIC Description: All Other Professional, Scientific, and Technical Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-02-01 TIA SALEMI
501 2016-02-01 TIA SALEMI

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2017-02-01	TIA SALEMI
501	2016-02-01	TIA SALEMI

Plan Statistics for H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN

401k plan membership statisitcs for H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN

Measure Date Value
2017: H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-02-01 107
Total number of active participants reported on line 7a of the Form 5500 2017-02-01 97
Total of all active and inactive participants 2017-02-01 97
Total participants 2017-02-01 97
2016: H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-02-01 100
Total number of active participants reported on line 7a of the Form 5500 2016-02-01 107
Total of all active and inactive participants 2016-02-01 107
Total participants 2016-02-01 107

Measure	Date	Value
2017: H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-02-01	107
Total number of active participants reported on line 7a of the Form 5500	2017-02-01	97
Total of all active and inactive participants	2017-02-01	97
Total participants	2017-02-01	97
2016: H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-02-01	100
Total number of active participants reported on line 7a of the Form 5500	2016-02-01	107
Total of all active and inactive participants	2016-02-01	107
Total participants	2016-02-01	107

Form 5500 Responses for H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN

2017: H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN 2017 form 5500 responses
2017-02-01	Type of plan entity	Single employer plan
2017-02-01	Plan funding arrangement – Insurance	Yes
2017-02-01	Plan benefit arrangement – Insurance	Yes
2016: H-O-H WATER TECHNOLOGY, INC. HEALTH & WELFARE PLAN 2016 form 5500 responses
2016-02-01	Type of plan entity	Single employer plan
2016-02-01	First time form 5500 has been submitted	Yes
2016-02-01	Plan funding arrangement – Insurance	Yes
2016-02-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

DEARBORN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 71129 )

Policy contract number

F1D0709

Policy instance

Insurance contract or identification number	F1D0709
Number of Individuals Covered	13
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $1,192
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	SHORT-TERM DISABILITY
Welfare Benefit Premiums Paid to Carrier	USD $7,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,192
Insurance broker organization code?	3
Insurance broker name	JEROME J. MANCUSO & ASSOCIATES

BLUECROSS BLUESHIELD OF TEXAS (National Association of Insurance Commissioners NAIC id number: 70670 )

Policy contract number

P42135

Policy instance

Insurance contract or identification number	P42135
Number of Individuals Covered	71
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $29,815
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $726,133
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,815
Insurance broker organization code?	3
Insurance broker name	JEROME J. MANCUSO & ASSOCIATES

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

Policy contract number

5641815

Policy instance

Insurance contract or identification number	5641815
Number of Individuals Covered	97
Insurance policy start date	2017-02-01
Insurance policy end date	2018-01-31
Total amount of commissions paid to insurance broker	USD $6,566
Total amount of fees paid to insurance company	USD $9,836
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $100,936
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	9836
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEES
Insurance broker organization code?	4
Commission paid to Insurance Broker	USD $6,566
Insurance broker name	JEROME J. MANCUSO & ASSOCIATES

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Company Name:	H-O-H WATER TECHNOLOGY, INC
Employer identification number (EIN):	362663459
NAIC Classification:	541990
NAIC Description:	All Other Professional, Scientific, and Technical Services