401k Plan data: POM, INC. HEALTH PLAN plan

POM, INC. HEALTH PLAN 401k Plan overview

Plan Name	POM, INC. HEALTH PLAN
Plan identification number	501

POM, INC. HEALTH PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Other welfare benefit cover

401k Sponsoring company profile

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

Company Name: POM, INC.

Employer identification number (EIN): 710551006

NAIC Classification: 334500

Additional information about POM, INC.

Jurisdiction of Incorporation: Nevada Department of State

Incorporation Date: 2005-10-03

Company Identification Number: 20051617802

Legal Registered Office Address: 7621 RIBBON ROCK COURT

LAS VEGAS
United States of America (USA)
89139

More information about POM, INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan POM, INC. HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2013-01-01
501 2012-01-01 MELISSA OATES
501 2011-01-01 MELISSA OATES
501 2009-01-01 MELISSA OATES

Plan Statistics for POM, INC. HEALTH PLAN

401k plan membership statisitcs for POM, INC. HEALTH PLAN

Measure Date Value
2013: POM, INC. HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 20
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 23
Total of all active and inactive participants 2013-01-01 23
2012: POM, INC. HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 23
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 20
Total of all active and inactive participants 2012-01-01 20
Total participants 2012-01-01 0
2011: POM, INC. HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 30
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 23
Total of all active and inactive participants 2011-01-01 23
Total participants 2011-01-01 23
2009: POM, INC. HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 29
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 26
Total of all active and inactive participants 2009-01-01 26
Total participants 2009-01-01 26

Measure	Date	Value
2013: POM, INC. HEALTH PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	20
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	23
Total of all active and inactive participants	2013-01-01	23
2012: POM, INC. HEALTH PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	23
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	20
Total of all active and inactive participants	2012-01-01	20
Total participants	2012-01-01	0
2011: POM, INC. HEALTH PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	30
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	23
Total of all active and inactive participants	2011-01-01	23
Total participants	2011-01-01	23
2009: POM, INC. HEALTH PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	29
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	26
Total of all active and inactive participants	2009-01-01	26
Total participants	2009-01-01	26

Form 5500 Responses for POM, INC. HEALTH PLAN

2013: POM, INC. HEALTH PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: POM, INC. HEALTH PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: POM, INC. HEALTH PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: POM, INC. HEALTH PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

126459

Policy instance

Insurance contract or identification number	126459
Number of Individuals Covered	8
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $1,845
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,845
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS7984

Policy instance

Insurance contract or identification number	VS7984
Number of Individuals Covered	14
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $662
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $662
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

2558

Policy instance

Insurance contract or identification number	2558
Number of Individuals Covered	49
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $1,556
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,556
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

513142

Policy instance

Insurance contract or identification number	513142
Number of Individuals Covered	41
Insurance policy start date	2013-01-01
Insurance policy end date	2014-01-01
Total amount of commissions paid to insurance broker	USD $201
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $201
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

QCA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95448 )

Policy contract number

60684

Policy instance

Insurance contract or identification number	60684
Number of Individuals Covered	67
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $8,667
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $8,667
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS7971

Policy instance

Insurance contract or identification number	VS7971
Number of Individuals Covered	14
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $379
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $379
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

QCA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95448 )

Policy contract number

60684

Policy instance

Insurance contract or identification number	60684
Number of Individuals Covered	67
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $9,154
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $9,154
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

513142

Policy instance

Insurance contract or identification number	513142
Number of Individuals Covered	31
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $230
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $230
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

126459

Policy instance

Insurance contract or identification number	126459
Number of Individuals Covered	8
Insurance policy start date	2012-01-01
Insurance policy end date	2013-01-01
Total amount of commissions paid to insurance broker	USD $1,925
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,925
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

2558

Policy instance

Insurance contract or identification number	2558
Number of Individuals Covered	44
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $1,129
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,129
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

513142

Policy instance

Insurance contract or identification number	513142
Number of Individuals Covered	35
Insurance policy start date	2011-01-01
Insurance policy end date	2012-01-01
Total amount of commissions paid to insurance broker	USD $216
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

126459

Policy instance

Insurance contract or identification number	126459
Number of Individuals Covered	9
Insurance policy start date	2011-01-01
Insurance policy end date	2012-01-01
Total amount of commissions paid to insurance broker	USD $1,544
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

2558

Policy instance

Insurance contract or identification number	2558
Number of Individuals Covered	48
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $1,502
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS7984

Policy instance

Insurance contract or identification number	VS7984
Number of Individuals Covered	18
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $800
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

QCA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95448 )

Policy contract number

60684

Policy instance

Insurance contract or identification number	60684
Number of Individuals Covered	73
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $11,086
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

QCA HEALTH PLAN (National Association of Insurance Commissioners NAIC id number: 95448 )

Policy contract number

60684

Policy instance

Insurance contract or identification number	60684
Number of Individuals Covered	77
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $13,848
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $13,848
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

513142

Policy instance

Insurance contract or identification number	513142
Number of Individuals Covered	43
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $229
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $2,033
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $229
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

126459

Policy instance

Insurance contract or identification number	126459
Number of Individuals Covered	10
Insurance policy start date	2010-01-01
Insurance policy end date	2011-01-01
Total amount of commissions paid to insurance broker	USD $1,762
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ADD
Welfare Benefit Premiums Paid to Carrier	USD $8,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,762
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

DELTA DENTAL PLAN OF ARKANSAS (National Association of Insurance Commissioners NAIC id number: 47155 )

Policy contract number

2558

Policy instance

Insurance contract or identification number	2558
Number of Individuals Covered	62
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $1,405
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,405
Insurance broker organization code?	3
Insurance broker name	HATCHER AGENCY

COMPBENEFITS (National Association of Insurance Commissioners NAIC id number: 60984 )

Policy contract number

VS7984

Policy instance

Insurance contract or identification number	VS7984
Number of Individuals Covered	13
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $512
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,842
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $512
Insurance broker name	HATCHER AGENCY

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Company Name:	POM, INC.
Employer identification number (EIN):	710551006
NAIC Classification:	334500

Jurisdiction of Incorporation:	Nevada Department of State
Incorporation Date:	2005-10-03
Company Identification Number:	20051617802
Legal Registered Office Address:	7621 RIBBON ROCK COURT LAS VEGAS United States of America (USA) 89139

Plan id#	Filing Submission Date	Name of Administrator
501	2013-01-01
501	2012-01-01	MELISSA OATES
501	2011-01-01	MELISSA OATES
501	2009-01-01	MELISSA OATES