401k Plan data: SIMKO SUPPORT CENTER WELFARE BENEFIT PLAN plan

SIMKO SUPPORT CENTER WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	SIMKO SUPPORT CENTER WELFARE BENEFIT PLAN
Plan identification number	501

SIMKO SUPPORT CENTER WELFARE BENEFIT 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) Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

SIMKO SUPPORT CENTER LLC has sponsored the creation of one or more 401k plans.

Company Name: SIMKO SUPPORT CENTER LLC

Employer identification number (EIN): 813450427

NAIC Classification: 621210
NAIC Description: Offices of Dentists

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SIMKO SUPPORT CENTER WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-01-01 STEVEN KRISTO 2021-08-30

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2020-01-01	STEVEN KRISTO	2021-08-30

Plan Statistics for SIMKO SUPPORT CENTER WELFARE BENEFIT PLAN

401k plan membership statisitcs for SIMKO SUPPORT CENTER WELFARE BENEFIT PLAN

Measure Date Value
2020: SIMKO SUPPORT CENTER WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 168
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 0
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 0
Number of employers contributing to the scheme 2020-01-01 0

Measure	Date	Value
2020: SIMKO SUPPORT CENTER WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	168
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	0
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	0
Number of employers contributing to the scheme	2020-01-01	0

Form 5500 Responses for SIMKO SUPPORT CENTER WELFARE BENEFIT PLAN

2020: SIMKO SUPPORT CENTER WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Mulitple employer plan
2020-01-01	First time form 5500 has been submitted	Yes
2020-01-01	This submission is the final filing	Yes
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

628527

Policy instance

Insurance contract or identification number	628527
Number of Individuals Covered	164
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $64,057
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,271,928
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	56237
Additional information about fees paid to insurance broker	BENEFIT ADVISOR FEES
Insurance broker organization code?	3

DELTA DENTAL OF WISCONSIN (National Association of Insurance Commissioners NAIC id number: 54046 )

Policy contract number

720

Policy instance

Insurance contract or identification number	720
Number of Individuals Covered	118
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,869
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $3,869
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10274511001

Policy instance

Insurance contract or identification number	10274511001
Number of Individuals Covered	161
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $867
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
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
Welfare Benefit Premiums Paid to Carrier	USD $9,583
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $867
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGM610887

Policy instance

Insurance contract or identification number	SGM610887
Number of Individuals Covered	160
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $5,279
Total amount of fees paid to insurance company	USD $192
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT,ACCIDENT,CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $47,250
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $5,279
Amount paid for insurance broker fees	192
Additional information about fees paid to insurance broker	OVERRIDE
Insurance broker organization code?	3

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Company Name:	SIMKO SUPPORT CENTER LLC
Employer identification number (EIN):	813450427
NAIC Classification:	621210
NAIC Description:	Offices of Dentists