401k Plan data: FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC plan

FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC 401k Plan overview

Plan Name	FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC
Plan identification number	501

FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision

401k Sponsoring company profile

DOMUS VITA, INC has sponsored the creation of one or more 401k plans.

Company Name: DOMUS VITA, INC

Employer identification number (EIN): 382651006

NAIC Classification: 623000
NAIC Description: Nursing and Residential Care Facilities

Form 5500 Filing Information

Submission information for form 5500 for 401k plan FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-01-01

Plan Statistics for FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC

401k plan membership statisitcs for FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC

Measure Date Value
2017: FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC 2017 401k membership
Total participants, beginning-of-year 2017-01-01 98
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 235
Total of all active and inactive participants 2017-01-01 235

Measure	Date	Value
2017: FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC 2017 401k membership
Total participants, beginning-of-year	2017-01-01	98
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	235
Total of all active and inactive participants	2017-01-01	235

Financial Data on FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC

Measure	Date	Value
2017 : FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC 2017 401k financial data
Total income from all sources	2017-12-31	$295,014
Expenses. Total of all expenses incurred	2017-12-31	$295,014
Benefits paid (including direct rollovers)	2017-12-31	$295,014
Total contributions received or receivable from participants	2017-12-31	$151,403
Net income (gross income less expenses)	2017-12-31	$0
Total contributions received or receivable from employer(s)	2017-12-31	$143,611

Form 5500 Responses for FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC

2017: FLEX COMP CAFETERIA PLAN OF DOMUS VITA, INC 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	First time form 5500 has been submitted	Yes
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1067965

Policy instance

Insurance contract or identification number	1067965
Number of Individuals Covered	96
Insurance policy start date	2016-09-01
Insurance policy end date	2017-08-31
Total amount of commissions paid to insurance broker	USD $2,652
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $25,223
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,652
Insurance broker organization code?	3
Insurance broker name	DALY-MERRIT INC

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60420

Policy instance

Insurance contract or identification number	M60420
Number of Individuals Covered	49
Insurance policy start date	2016-09-01
Insurance policy end date	2017-08-31
Total amount of commissions paid to insurance broker	USD $6,198
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $193,929
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,198
Insurance broker organization code?	3
Insurance broker name	DALY-MERRIT INC

TOTAL HEALTH CARE USA INC (National Association of Insurance Commissioners NAIC id number: 12326 )

Policy contract number

M60420COBRA

Policy instance

Insurance contract or identification number	M60420COBRA
Number of Individuals Covered	1
Insurance policy start date	2016-09-01
Insurance policy end date	2017-08-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $3,164
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

82-2723296

Policy instance

Insurance contract or identification number	82-2723296
Number of Individuals Covered	89
Insurance policy start date	2016-09-01
Insurance policy end date	2017-08-31
Total amount of commissions paid to insurance broker	USD $15,966
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $60,631
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $15,193
Insurance broker name

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Company Name:	DOMUS VITA, INC
Employer identification number (EIN):	382651006
NAIC Classification:	623000
NAIC Description:	Nursing and Residential Care Facilities