401k Plan data: GREAT LAKES LASER DYNAMICS, INC. GROUP HEALTH PLAN plan

GREAT LAKES LASER DYNAMICS, INC. GROUP HEALTH PLAN 401k Plan overview

Plan Name	GREAT LAKES LASER DYNAMICS, INC. GROUP HEALTH PLAN
Plan identification number	510

GREAT LAKES LASER DYNAMICS, INC. GROUP HEALTH 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 Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

GREAT LAKES LASER DYNAMICS has sponsored the creation of one or more 401k plans.

Company Name: GREAT LAKES LASER DYNAMICS

Employer identification number (EIN): 383511123

NAIC Classification: 332900

Form 5500 Filing Information

Submission information for form 5500 for 401k plan GREAT LAKES LASER DYNAMICS, INC. GROUP HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
510 2018-12-01 BILL HERBERG 2020-05-14

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
510	2018-12-01	BILL HERBERG	2020-05-14

Plan Statistics for GREAT LAKES LASER DYNAMICS, INC. GROUP HEALTH PLAN

401k plan membership statisitcs for GREAT LAKES LASER DYNAMICS, INC. GROUP HEALTH PLAN

Measure Date Value
2018: GREAT LAKES LASER DYNAMICS, INC. GROUP HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year 2018-12-01 118
Total number of active participants reported on line 7a of the Form 5500 2018-12-01 72
Number of retired or separated participants receiving benefits 2018-12-01 0
Number of other retired or separated participants entitled to future benefits 2018-12-01 0
Total of all active and inactive participants 2018-12-01 72
Number of employers contributing to the scheme 2018-12-01 0

Measure	Date	Value
2018: GREAT LAKES LASER DYNAMICS, INC. GROUP HEALTH PLAN 2018 401k membership
Total participants, beginning-of-year	2018-12-01	118
Total number of active participants reported on line 7a of the Form 5500	2018-12-01	72
Number of retired or separated participants receiving benefits	2018-12-01	0
Number of other retired or separated participants entitled to future benefits	2018-12-01	0
Total of all active and inactive participants	2018-12-01	72
Number of employers contributing to the scheme	2018-12-01	0

Form 5500 Responses for GREAT LAKES LASER DYNAMICS, INC. GROUP HEALTH PLAN

2018: GREAT LAKES LASER DYNAMICS, INC. GROUP HEALTH PLAN 2018 form 5500 responses
2018-12-01	Type of plan entity	Single employer plan
2018-12-01	First time form 5500 has been submitted	Yes
2018-12-01	Plan funding arrangement – Insurance	Yes
2018-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2018-12-01	Plan benefit arrangement – Insurance	Yes
2018-12-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

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

Policy contract number

98342351001

Policy instance

Insurance contract or identification number	98342351001
Number of Individuals Covered	148
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $1,105
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,178
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,105
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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

Policy contract number

6831

Policy instance

Insurance contract or identification number	6831
Number of Individuals Covered	174
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $7,243
Total amount of fees paid to insurance company	USD $409
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 $7,243
Amount paid for insurance broker fees	409
Additional information about fees paid to insurance broker	NEW BUSINESS BONUS RETENTION BONUS
Insurance broker organization code?	3

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

Policy contract number

GLTD0AY9F

Policy instance

Insurance contract or identification number	GLTD0AY9F
Number of Individuals Covered	147
Insurance policy start date	2018-12-01
Insurance policy end date	2019-11-30
Total amount of commissions paid to insurance broker	USD $13,174
Total amount of fees paid to insurance company	USD $4,792
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $87,823
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,174
Amount paid for insurance broker fees	4792
Additional information about fees paid to insurance broker	OTHER COMPENSATION
Insurance broker organization code?	3

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Company Name:	GREAT LAKES LASER DYNAMICS
Employer identification number (EIN):	383511123
NAIC Classification:	332900