401k Plan data: 180 MEDICAL VISION PLAN plan

180 MEDICAL VISION PLAN 401k Plan overview

Plan Name	180 MEDICAL VISION PLAN
Plan identification number	503

180 MEDICAL VISION PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Vision

401k Sponsoring company profile

180 MEDICAL, INC. has sponsored the creation of one or more 401k plans.

Company Name: 180 MEDICAL, INC.

Employer identification number (EIN): 134311220

NAIC Classification: 446190

Form 5500 Filing Information

Submission information for form 5500 for 401k plan 180 MEDICAL VISION PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2014-01-01 SHARON ZAJAC SHARON ZAJAC 2015-01-29
503 2012-01-01 SHARON ZAJAC SHARON ZAJAC 2014-02-07

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
503	2014-01-01	SHARON ZAJAC		SHARON ZAJAC	2015-01-29
503	2012-01-01	SHARON ZAJAC		SHARON ZAJAC	2014-02-07

Plan Statistics for 180 MEDICAL VISION PLAN

401k plan membership statisitcs for 180 MEDICAL VISION PLAN

Measure Date Value
2014: 180 MEDICAL VISION PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 114
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 152
Total of all active and inactive participants 2014-01-01 152
Total participants 2014-01-01 152
2012: 180 MEDICAL VISION PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 86
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 114
Total of all active and inactive participants 2012-01-01 114
Total participants 2012-01-01 114

Measure	Date	Value
2014: 180 MEDICAL VISION PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	114
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	152
Total of all active and inactive participants	2014-01-01	152
Total participants	2014-01-01	152
2012: 180 MEDICAL VISION PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	86
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	114
Total of all active and inactive participants	2012-01-01	114
Total participants	2012-01-01	114

Form 5500 Responses for 180 MEDICAL VISION PLAN

2014: 180 MEDICAL VISION PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	First time form 5500 has been submitted	Yes
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2012: 180 MEDICAL VISION PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	First time form 5500 has been submitted	Yes
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )

Policy contract number

30014542

Policy instance

Insurance contract or identification number	30014542
Number of Individuals Covered	152
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,392
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	No
Vision Insurance Welfare Benefit	Yes
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 $29,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $496
Insurance broker organization code?	3
Insurance broker name	STRATEGIC EMPLOYEE BENEFIT SERVICES

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 95478 )

Policy contract number

30014542

Policy instance

Insurance contract or identification number	30014542
Number of Individuals Covered	114
Insurance policy start date	2012-07-01
Insurance policy end date	2013-06-30
Total amount of commissions paid to insurance broker	USD $1,093
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	No
Vision Insurance Welfare Benefit	Yes
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 $19,648
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,093
Insurance broker organization code?	3
Insurance broker name	STOCKTON AND ASSOCIATES

Potentially related plans

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Company Name:	180 MEDICAL, INC.
Employer identification number (EIN):	134311220
NAIC Classification:	446190