401k Plan data: COST OF WISCONSIN EMPLOYEE DENTAL/VISION plan

COST OF WISCONSIN EMPLOYEE DENTAL/VISION 401k Plan overview

Plan Name	COST OF WISCONSIN EMPLOYEE DENTAL/VISION
Plan identification number	503

COST OF WISCONSIN EMPLOYEE DENTAL/VISION Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Dental 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

COST OF WISCONSIN, INC. has sponsored the creation of one or more 401k plans.

Company Name: COST OF WISCONSIN, INC.

Employer identification number (EIN): 391089478

NAIC Classification: 238300

Form 5500 Filing Information

Submission information for form 5500 for 401k plan COST OF WISCONSIN EMPLOYEE DENTAL/VISION

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
503 2017-01-01 ROGER SCHRIEBER
503 2016-01-01 ROGER SCHRIEBER ROGER SCHRIEBER 2017-07-27

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
503	2017-01-01	ROGER SCHRIEBER
503	2016-01-01	ROGER SCHRIEBER		ROGER SCHRIEBER	2017-07-27

Plan Statistics for COST OF WISCONSIN EMPLOYEE DENTAL/VISION

401k plan membership statisitcs for COST OF WISCONSIN EMPLOYEE DENTAL/VISION

Measure Date Value
2017: COST OF WISCONSIN EMPLOYEE DENTAL/VISION 2017 401k membership
Total participants, beginning-of-year 2017-01-01 138
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 57
Total of all active and inactive participants 2017-01-01 57
2016: COST OF WISCONSIN EMPLOYEE DENTAL/VISION 2016 401k membership
Total participants, beginning-of-year 2016-01-01 153
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 138
Total of all active and inactive participants 2016-01-01 138
Total participants 2016-01-01 138

Measure	Date	Value
2017: COST OF WISCONSIN EMPLOYEE DENTAL/VISION 2017 401k membership
Total participants, beginning-of-year	2017-01-01	138
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	57
Total of all active and inactive participants	2017-01-01	57
2016: COST OF WISCONSIN EMPLOYEE DENTAL/VISION 2016 401k membership
Total participants, beginning-of-year	2016-01-01	153
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	138
Total of all active and inactive participants	2016-01-01	138
Total participants	2016-01-01	138

Form 5500 Responses for COST OF WISCONSIN EMPLOYEE DENTAL/VISION

2017: COST OF WISCONSIN EMPLOYEE DENTAL/VISION 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: COST OF WISCONSIN EMPLOYEE DENTAL/VISION 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	First time form 5500 has been submitted	Yes
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )

Policy contract number

710005

Policy instance

Insurance contract or identification number	710005
Number of Individuals Covered	57
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $5,947
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $52,505
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,947
Insurance broker organization code?	3
Insurance broker name	WOLLER ANGER & CO, LLC

Potentially related plans

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Company Name:	COST OF WISCONSIN, INC.
Employer identification number (EIN):	391089478
NAIC Classification:	238300