401k Plan data: DEARBORN MID-WEST COMPANY, LLC EMPLOYEE BENEFIT PLAN plan

DEARBORN MID-WEST COMPANY, LLC EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	DEARBORN MID-WEST COMPANY, LLC EMPLOYEE BENEFIT PLAN
Plan identification number	501

DEARBORN MID-WEST COMPANY, LLC EMPLOYEE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

DEARBORN MID-WEST COMPANY, LLC has sponsored the creation of one or more 401k plans.

Company Name: DEARBORN MID-WEST COMPANY, LLC

Employer identification number (EIN): 472254578

NAIC Classification: 238900

Additional information about DEARBORN MID-WEST COMPANY, LLC

Jurisdiction of Incorporation: Texas Secretary of State

Incorporation Date: 2015-01-30

Company Identification Number: 0802147210

Legal Registered Office Address: 20334 SUPERIOR RD

TAYLOR
United States of America (USA)
48180

More information about DEARBORN MID-WEST COMPANY, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DEARBORN MID-WEST COMPANY, LLC EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-03-01 KELLY SCHAFER

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2015-03-01	KELLY SCHAFER

Plan Statistics for DEARBORN MID-WEST COMPANY, LLC EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for DEARBORN MID-WEST COMPANY, LLC EMPLOYEE BENEFIT PLAN

Measure Date Value
2015: DEARBORN MID-WEST COMPANY, LLC EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-03-01 147
Total number of active participants reported on line 7a of the Form 5500 2015-03-01 136
Number of retired or separated participants receiving benefits 2015-03-01 0
Number of other retired or separated participants entitled to future benefits 2015-03-01 0
Total of all active and inactive participants 2015-03-01 136

Measure	Date	Value
2015: DEARBORN MID-WEST COMPANY, LLC EMPLOYEE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-03-01	147
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	136
Number of retired or separated participants receiving benefits	2015-03-01	0
Number of other retired or separated participants entitled to future benefits	2015-03-01	0
Total of all active and inactive participants	2015-03-01	136

Form 5500 Responses for DEARBORN MID-WEST COMPANY, LLC EMPLOYEE BENEFIT PLAN

2015: DEARBORN MID-WEST COMPANY, LLC EMPLOYEE BENEFIT PLAN 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	First time form 5500 has been submitted	Yes
2015-03-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

DELTA DENTAL OF MICHIGAN (National Association of Insurance Commissioners NAIC id number: 54305 )

Policy contract number

3171

Policy instance

Insurance contract or identification number	3171
Number of Individuals Covered	160
Insurance policy start date	2015-03-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $4,078
Dental 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 $4,078
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

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

Policy contract number

1000170

Policy instance

Insurance contract or identification number	1000170
Number of Individuals Covered	30
Insurance policy start date	2015-03-01
Insurance policy end date	2015-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

875851G

Policy instance

Insurance contract or identification number	875851G
Number of Individuals Covered	251
Insurance policy start date	2015-03-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,230
Total amount of fees paid to insurance company	USD $3,816
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $55,950
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,230
Amount paid for insurance broker fees	3816
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )

Policy contract number

665104

Policy instance

Insurance contract or identification number	665104
Number of Individuals Covered	17
Insurance policy start date	2015-03-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $3,515
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $104,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,515
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

HEALTH ALLIANCE PLAN (National Association of Insurance Commissioners NAIC id number: 95844 )

Policy contract number

10002562

Policy instance

Insurance contract or identification number	10002562
Number of Individuals Covered	83
Insurance policy start date	2015-03-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $21,946
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $447,725
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $21,946
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

Potentially related plans

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Company Name:	DEARBORN MID-WEST COMPANY, LLC
Employer identification number (EIN):	472254578
NAIC Classification:	238900

Jurisdiction of Incorporation:	Texas Secretary of State
Incorporation Date:	2015-01-30
Company Identification Number:	0802147210
Legal Registered Office Address:	20334 SUPERIOR RD TAYLOR United States of America (USA) 48180