401k Plan data: DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM plan

DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM 401k Plan overview

Plan Name	DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM
Plan identification number	504

DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Dental Long-term disability cover

401k Sponsoring company profile

DONNELLY COMMUNICATIONS INC. has sponsored the creation of one or more 401k plans.

Company Name: DONNELLY COMMUNICATIONS INC.

Employer identification number (EIN): 630811791

NAIC Classification: 561420

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
504 2016-06-01 PAMELA CARTER
504 2014-06-01 EVELYN JACKSON

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
504	2016-06-01	PAMELA CARTER
504	2014-06-01	EVELYN JACKSON

Plan Statistics for DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM

401k plan membership statisitcs for DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM

Measure Date Value
2016: DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM 2016 401k membership
Total participants, beginning-of-year 2016-06-01 241
Total number of active participants reported on line 7a of the Form 5500 2016-06-01 163
Number of retired or separated participants receiving benefits 2016-06-01 0
Number of other retired or separated participants entitled to future benefits 2016-06-01 0
Total of all active and inactive participants 2016-06-01 163
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-06-01 0
Total participants 2016-06-01 163
Number of participants with account balances 2016-06-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-06-01 0
Number of employers contributing to the scheme 2016-06-01 0
2014: DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM 2014 401k membership
Total participants, beginning-of-year 2014-06-01 66
Total number of active participants reported on line 7a of the Form 5500 2014-06-01 175
Number of retired or separated participants receiving benefits 2014-06-01 0
Number of other retired or separated participants entitled to future benefits 2014-06-01 0
Total of all active and inactive participants 2014-06-01 175
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-06-01 0
Total participants 2014-06-01 175
Number of participants with account balances 2014-06-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-06-01 0

Measure	Date	Value
2016: DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM 2016 401k membership
Total participants, beginning-of-year	2016-06-01	241
Total number of active participants reported on line 7a of the Form 5500	2016-06-01	163
Number of retired or separated participants receiving benefits	2016-06-01	0
Number of other retired or separated participants entitled to future benefits	2016-06-01	0
Total of all active and inactive participants	2016-06-01	163
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-06-01	0
Total participants	2016-06-01	163
Number of participants with account balances	2016-06-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-06-01	0
Number of employers contributing to the scheme	2016-06-01	0
2014: DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM 2014 401k membership
Total participants, beginning-of-year	2014-06-01	66
Total number of active participants reported on line 7a of the Form 5500	2014-06-01	175
Number of retired or separated participants receiving benefits	2014-06-01	0
Number of other retired or separated participants entitled to future benefits	2014-06-01	0
Total of all active and inactive participants	2014-06-01	175
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-06-01	0
Total participants	2014-06-01	175
Number of participants with account balances	2014-06-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-06-01	0

Form 5500 Responses for DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM

2016: DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM 2016 form 5500 responses
2016-06-01	Type of plan entity	Single employer plan
2016-06-01	First time form 5500 has been submitted	Yes
2016-06-01	Submission has been amended	No
2016-06-01	This submission is the final filing	No
2016-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-06-01	Plan is a collectively bargained plan	No
2016-06-01	Plan funding arrangement – Insurance	Yes
2016-06-01	Plan benefit arrangement – Insurance	Yes
2014: DONNELLY COMMUNICATIONS VOLUNTARY DENTAL PROGRAM 2014 form 5500 responses
2014-06-01	Type of plan entity	Single employer plan
2014-06-01	First time form 5500 has been submitted	Yes
2014-06-01	Submission has been amended	No
2014-06-01	This submission is the final filing	No
2014-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-06-01	Plan is a collectively bargained plan	No
2014-06-01	Plan funding arrangement – Insurance	Yes
2014-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

MUTUAL OF OMAHA (National Association of Insurance Commissioners NAIC id number: 69868 )

Policy contract number

G000APTS

Policy instance

Insurance contract or identification number	G000APTS
Number of Individuals Covered	175
Insurance policy start date	2014-06-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $3,170
Total amount of fees paid to insurance company	USD $0
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	No
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 $85,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,170
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	PERSPECTIVE BENEFITS CONSULTING, IN

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Company Name:	DONNELLY COMMUNICATIONS INC.
Employer identification number (EIN):	630811791
NAIC Classification:	561420