401k Plan data: MOMS ORGANIC MARKET MEDICAL PLAN plan

MOMS ORGANIC MARKET MEDICAL PLAN 401k Plan overview

Plan Name	MOMS ORGANIC MARKET MEDICAL PLAN
Plan identification number	501

MOMS ORGANIC MARKET MEDICAL PLAN Benefits

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

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): 453943663

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MOMS ORGANIC MARKET MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-09-01 KELLY MOLER
501 2015-09-01 PATRICIA KOTLER

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2016-09-01	KELLY MOLER
501	2015-09-01	PATRICIA KOTLER

Plan Statistics for MOMS ORGANIC MARKET MEDICAL PLAN

401k plan membership statisitcs for MOMS ORGANIC MARKET MEDICAL PLAN

Measure Date Value
2016: MOMS ORGANIC MARKET MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year 2016-09-01 398
Total number of active participants reported on line 7a of the Form 5500 2016-09-01 458
Number of retired or separated participants receiving benefits 2016-09-01 0
Number of other retired or separated participants entitled to future benefits 2016-09-01 0
Total of all active and inactive participants 2016-09-01 458
2015: MOMS ORGANIC MARKET MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year 2015-09-01 284
Total number of active participants reported on line 7a of the Form 5500 2015-09-01 398
Number of retired or separated participants receiving benefits 2015-09-01 0
Number of other retired or separated participants entitled to future benefits 2015-09-01 0
Total of all active and inactive participants 2015-09-01 398

Measure	Date	Value
2016: MOMS ORGANIC MARKET MEDICAL PLAN 2016 401k membership
Total participants, beginning-of-year	2016-09-01	398
Total number of active participants reported on line 7a of the Form 5500	2016-09-01	458
Number of retired or separated participants receiving benefits	2016-09-01	0
Number of other retired or separated participants entitled to future benefits	2016-09-01	0
Total of all active and inactive participants	2016-09-01	458
2015: MOMS ORGANIC MARKET MEDICAL PLAN 2015 401k membership
Total participants, beginning-of-year	2015-09-01	284
Total number of active participants reported on line 7a of the Form 5500	2015-09-01	398
Number of retired or separated participants receiving benefits	2015-09-01	0
Number of other retired or separated participants entitled to future benefits	2015-09-01	0
Total of all active and inactive participants	2015-09-01	398

Form 5500 Responses for MOMS ORGANIC MARKET MEDICAL PLAN

2016: MOMS ORGANIC MARKET MEDICAL PLAN 2016 form 5500 responses
2016-09-01	Type of plan entity	Single employer plan
2016-09-01	Submission has been amended	No
2016-09-01	This submission is the final filing	No
2016-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-09-01	Plan is a collectively bargained plan	No
2016-09-01	Plan funding arrangement – Insurance	Yes
2016-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-09-01	Plan benefit arrangement – Insurance	Yes
2016-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: MOMS ORGANIC MARKET MEDICAL PLAN 2015 form 5500 responses
2015-09-01	Type of plan entity	Single employer plan
2015-09-01	Submission has been amended	No
2015-09-01	This submission is the final filing	No
2015-09-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-09-01	Plan is a collectively bargained plan	No
2015-09-01	Plan funding arrangement – Insurance	Yes
2015-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-09-01	Plan benefit arrangement – Insurance	Yes
2015-09-01	Plan benefit arrangement – General assets of the sponsor	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

424952

Policy instance

Insurance contract or identification number	424952
Number of Individuals Covered	345
Insurance policy start date	2015-09-01
Insurance policy end date	2016-08-31
Total amount of commissions paid to insurance broker	USD $8,450
Total amount of fees paid to insurance company	USD $5,537
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 $192,426
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,849
Insurance broker organization code?	3
Amount paid for insurance broker fees	5537
Additional information about fees paid to insurance broker	FEES
Insurance broker name	CORPORATE SYNERGIES GROUP, LLC

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Company Name:	MOMS ORGANIC MARKET
Employer identification number (EIN):	453943663
NAIC Classification:	445299
NAIC Description:	All Other Specialty Food Stores