401k Plan data: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT plan

DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 401k Plan overview

Plan Name	DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT
Plan identification number	502

DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 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 Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

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

Company Name: DLSM, INC.

Employer identification number (EIN): 391320531

NAIC Classification: 332110

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2017-01-01
502 2016-01-01
502 2015-01-01
502 2014-01-01 DAVID WOLFE
502 2014-01-01 JOHN DELISIO
502 2013-01-01 DAVID WOLFE
502 2012-01-01 DAVID WOLFE
502 2011-01-01 DAVID WOLFE

Plan Statistics for DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT

401k plan membership statisitcs for DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT

Measure Date Value
2017: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2017 401k membership
Total participants, beginning-of-year 2017-01-01 229
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 234
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 234
2016: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2016 401k membership
Total participants, beginning-of-year 2016-01-01 241
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 231
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 231
2015: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2015 401k membership
Total participants, beginning-of-year 2015-01-01 253
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 243
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 243
2014: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2014 401k membership
Total participants, beginning-of-year 2014-01-01 234
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 256
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 256
2013: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2013 401k membership
Total participants, beginning-of-year 2013-01-01 204
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 226
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 226
2012: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2012 401k membership
Total participants, beginning-of-year 2012-01-01 204
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 205
Number of retired or separated participants receiving benefits 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 205
2011: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2011 401k membership
Total participants, beginning-of-year 2011-01-01 187
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 205
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 0
Total of all active and inactive participants 2011-01-01 205

Measure	Date	Value
2017: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2017 401k membership
Total participants, beginning-of-year	2017-01-01	229
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	234
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	234
2016: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2016 401k membership
Total participants, beginning-of-year	2016-01-01	241
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	231
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	231
2015: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2015 401k membership
Total participants, beginning-of-year	2015-01-01	253
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	243
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	243
2014: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2014 401k membership
Total participants, beginning-of-year	2014-01-01	234
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	256
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	256
2013: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2013 401k membership
Total participants, beginning-of-year	2013-01-01	204
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	226
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	226
2012: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2012 401k membership
Total participants, beginning-of-year	2012-01-01	204
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	205
Number of retired or separated participants receiving benefits	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	205
2011: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2011 401k membership
Total participants, beginning-of-year	2011-01-01	187
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	205
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	0
Total of all active and inactive participants	2011-01-01	205

Form 5500 Responses for DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT

2017: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 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 – General assets of the sponsor	Yes
2017-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2016: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
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 – General assets of the sponsor	Yes
2016-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
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 funding arrangement – General assets of the sponsor	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
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 – General assets of the sponsor	Yes
2012-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: DLSM, INC. SECTION 105 HEALTH REIMBURSEMENT ARRANGEMENT 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	First time form 5500 has been submitted	Yes
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number	00221320
Policy instance	1
COMPCARE HEALTH SERVICES INSURANCE CORPORATION (National Association of Insurance Commissioners NAIC id number: 95693 )
Policy contract number	00221320
Policy instance	2
SUPERIOR VISION INSURANCE PLAN OF WISCONSIN, INC (National Association of Insurance Commissioners NAIC id number: 52005 )
Policy contract number	142400
Policy instance	3
METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )
Policy contract number	KM05997104
Policy instance	4

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Company Name:	DLSM, INC.
Employer identification number (EIN):	391320531
NAIC Classification:	332110