401k Plan data: CCP DIVISION EMPLOYEE BENEFITS PLAN plan

CCP DIVISION EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	CCP DIVISION EMPLOYEE BENEFITS PLAN
Plan identification number	502

CCP DIVISION EMPLOYEE BENEFITS PLAN Benefits

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

401k Sponsoring company profile

POLYNT COMPOSITES USA, INC. has sponsored the creation of one or more 401k plans.

Company Name: POLYNT COMPOSITES USA, INC.

Employer identification number (EIN): 990365117

NAIC Classification: 325500

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CCP DIVISION EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2015-01-01 DEBBIE HUDSON

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2015-01-01	DEBBIE HUDSON

Plan Statistics for CCP DIVISION EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for CCP DIVISION EMPLOYEE BENEFITS PLAN

Measure Date Value
2015: CCP DIVISION EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 145
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 0
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 0

Measure	Date	Value
2015: CCP DIVISION EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	145
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	0
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	0

Form 5500 Responses for CCP DIVISION EMPLOYEE BENEFITS PLAN

2015: CCP DIVISION EMPLOYEE BENEFITS 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	This submission is the final filing	Yes
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

AETNA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60054 )

Policy contract number

0869551

Policy instance

Insurance contract or identification number	0869551
Number of Individuals Covered	379
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $253
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,830,776
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $253
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

700287

Policy instance

Insurance contract or identification number	700287
Number of Individuals Covered	189
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,010
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

700148

Policy instance

Insurance contract or identification number	700148
Number of Individuals Covered	166
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of fees paid to insurance company	USD $1,421
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $28,412
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	1421
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANIES, LLC.

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

3338676

Policy instance

Insurance contract or identification number	3338676
Number of Individuals Covered	150
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $124,064
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 93440 )

Policy contract number

5407510010DVIO

Policy instance

Insurance contract or identification number	5407510010DVIO
Number of Individuals Covered	125
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $21,082
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

KM05924231

Policy instance

Insurance contract or identification number	KM05924231
Number of Individuals Covered	287
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of fees paid to insurance company	USD $2,219
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $108,781
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Amount paid for insurance broker fees	2219
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMPENSATION NON-MONETARY COMPENSATION
Insurance broker organization code?	3
Insurance broker name	LOCKTON COMPANY, LLC.

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Company Name:	POLYNT COMPOSITES USA, INC.
Employer identification number (EIN):	990365117
NAIC Classification:	325500