401k Plan data: MOM'S ORGANIC MARKET MEDICAL PLAN plan

MOM'S ORGANIC MARKET MEDICAL PLAN 401k Plan overview

Plan Name	MOM'S ORGANIC MARKET MEDICAL PLAN
Plan identification number	501

MOM'S ORGANIC MARKET MEDICAL PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision Other welfare benefit cover

401k Sponsoring company profile

MOMS ORGANIC MARKET has sponsored the creation of one or more 401k plans.

Company Name: MOMS ORGANIC MARKET

Employer identification number (EIN): 300079838

NAIC Classification: 445299
NAIC Description: All Other Specialty Food Stores

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MOM'S ORGANIC MARKET MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2014-09-01 GLORIA GARBER
501 2013-09-01 GLORIA GARBER
501 2012-09-01 MOLLY VLHOV

Plan id#	Filing Submission Date	Name of Administrator
501	2014-09-01	GLORIA GARBER
501	2013-09-01	GLORIA GARBER
501	2012-09-01	MOLLY VLHOV

Plan Statistics for MOM'S ORGANIC MARKET MEDICAL PLAN

401k plan membership statisitcs for MOM'S ORGANIC MARKET MEDICAL PLAN

Measure Date Value
2014: MOM'S ORGANIC MARKET MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year 2014-09-01 302
Total number of active participants reported on line 7a of the Form 5500 2014-09-01 284
Number of retired or separated participants receiving benefits 2014-09-01 0
Number of other retired or separated participants entitled to future benefits 2014-09-01 0
Total of all active and inactive participants 2014-09-01 284
2013: MOM'S ORGANIC MARKET MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year 2013-09-01 213
Total number of active participants reported on line 7a of the Form 5500 2013-09-01 233
Number of retired or separated participants receiving benefits 2013-09-01 0
Number of other retired or separated participants entitled to future benefits 2013-09-01 0
Total of all active and inactive participants 2013-09-01 233
2012: MOM'S ORGANIC MARKET MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year 2012-09-01 135
Total number of active participants reported on line 7a of the Form 5500 2012-09-01 159
Number of retired or separated participants receiving benefits 2012-09-01 0
Number of other retired or separated participants entitled to future benefits 2012-09-01 0
Total of all active and inactive participants 2012-09-01 159

Measure	Date	Value
2014: MOM'S ORGANIC MARKET MEDICAL PLAN 2014 401k membership
Total participants, beginning-of-year	2014-09-01	302
Total number of active participants reported on line 7a of the Form 5500	2014-09-01	284
Number of retired or separated participants receiving benefits	2014-09-01	0
Number of other retired or separated participants entitled to future benefits	2014-09-01	0
Total of all active and inactive participants	2014-09-01	284
2013: MOM'S ORGANIC MARKET MEDICAL PLAN 2013 401k membership
Total participants, beginning-of-year	2013-09-01	213
Total number of active participants reported on line 7a of the Form 5500	2013-09-01	233
Number of retired or separated participants receiving benefits	2013-09-01	0
Number of other retired or separated participants entitled to future benefits	2013-09-01	0
Total of all active and inactive participants	2013-09-01	233
2012: MOM'S ORGANIC MARKET MEDICAL PLAN 2012 401k membership
Total participants, beginning-of-year	2012-09-01	135
Total number of active participants reported on line 7a of the Form 5500	2012-09-01	159
Number of retired or separated participants receiving benefits	2012-09-01	0
Number of other retired or separated participants entitled to future benefits	2012-09-01	0
Total of all active and inactive participants	2012-09-01	159

Form 5500 Responses for MOM'S ORGANIC MARKET MEDICAL PLAN

2014: MOM'S ORGANIC MARKET MEDICAL PLAN 2014 form 5500 responses
2014-09-01	Type of plan entity	Single employer plan
2014-09-01	Submission has been amended	No
2014-09-01	This submission is the final filing	No
2014-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-09-01	Plan is a collectively bargained plan	No
2014-09-01	Plan funding arrangement – Insurance	Yes
2014-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-09-01	Plan benefit arrangement – Insurance	Yes
2014-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: MOM'S ORGANIC MARKET MEDICAL PLAN 2013 form 5500 responses
2013-09-01	Type of plan entity	Single employer plan
2013-09-01	Submission has been amended	No
2013-09-01	This submission is the final filing	No
2013-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-09-01	Plan is a collectively bargained plan	No
2013-09-01	Plan funding arrangement – Insurance	Yes
2013-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-09-01	Plan benefit arrangement – Insurance	Yes
2013-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: MOM'S ORGANIC MARKET MEDICAL PLAN 2012 form 5500 responses
2012-09-01	Type of plan entity	Single employer plan
2012-09-01	First time form 5500 has been submitted	Yes
2012-09-01	Submission has been amended	No
2012-09-01	This submission is the final filing	No
2012-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-09-01	Plan is a collectively bargained plan	No
2012-09-01	Plan funding arrangement – Insurance	Yes
2012-09-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00424952

Policy instance

Insurance contract or identification number	00424952
Number of Individuals Covered	257
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $6,163
Total amount of fees paid to insurance company	USD $3,172
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	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 $140,420
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,355
Amount paid for insurance broker fees	3172
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	GROUP BENEFIT SERVICES

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

VARIOUS

Policy instance

Insurance contract or identification number	VARIOUS
Number of Individuals Covered	284
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $40,819
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	No
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 $428,874
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $40,819
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFIT SERVICES

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00424952

Policy instance

Insurance contract or identification number	00424952
Number of Individuals Covered	203
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $5,670
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	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 $131,573
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,038
Insurance broker organization code?	3
Insurance broker name	STEVEN L CRAWFORD

UNIMERICA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 91529 )

Policy contract number

VARIOUS

Policy instance

Insurance contract or identification number	VARIOUS
Number of Individuals Covered	233
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $15,308
Total amount of fees paid to insurance company	USD $5,778
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	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 $283,709
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,308
Amount paid for insurance broker fees	5778
Additional information about fees paid to insurance broker	BONUS
Insurance broker organization code?	3
Insurance broker name	GROUP BENEFIT SERVICES

CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )

Policy contract number

0NJN

Policy instance

Insurance contract or identification number	0NJN
Number of Individuals Covered	159
Insurance policy start date	2012-09-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $20,423
Total amount of fees paid to insurance company	USD $11,703
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	Yes
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 $581,273
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $20,423
Amount paid for insurance broker fees	11703
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3
Insurance broker name	EMPLOYEE BENEFIT SERVICES OF MD

Potentially related plans

MOM'S ORGANIC MARKET, INC. [EIN = 521672795]

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Company Name:	MOMS ORGANIC MARKET
Employer identification number (EIN):	300079838
NAIC Classification:	445299
NAIC Description:	All Other Specialty Food Stores