401k Plan data: VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN plan

VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN 401k Plan overview

Plan Name	VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN
Plan identification number	501

VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN Benefits

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

VISTRA INTERNATIONAL EXPANSION (USA), INC. has sponsored the creation of one or more 401k plans.

Company Name: VISTRA INTERNATIONAL EXPANSION (USA), INC.

Employer identification number (EIN): 900599705

NAIC Classification: 541600

Form 5500 Filing Information

Submission information for form 5500 for 401k plan VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2021-06-01 MIRIAM ECHEVARRIA 2022-11-21
501 2020-06-01 MATTHEW KUPFER 2021-11-19
501 2019-06-01 DEBORAH A. DIZOGLIO 2020-11-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2021-06-01	MIRIAM ECHEVARRIA	2022-11-21
501	2020-06-01	MATTHEW KUPFER	2021-11-19
501	2019-06-01	DEBORAH A. DIZOGLIO	2020-11-13

Plan Statistics for VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN

401k plan membership statisitcs for VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN

Measure Date Value
2021: VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN 2021 401k membership
Total participants, beginning-of-year 2021-06-01 131
Total number of active participants reported on line 7a of the Form 5500 2021-06-01 0
Number of retired or separated participants receiving benefits 2021-06-01 0
Number of other retired or separated participants entitled to future benefits 2021-06-01 0
Total of all active and inactive participants 2021-06-01 0
2020: VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN 2020 401k membership
Total participants, beginning-of-year 2020-06-01 110
Total number of active participants reported on line 7a of the Form 5500 2020-06-01 86
Number of retired or separated participants receiving benefits 2020-06-01 6
Number of other retired or separated participants entitled to future benefits 2020-06-01 0
Total of all active and inactive participants 2020-06-01 92
Number of employers contributing to the scheme 2020-06-01 0
2019: VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN 2019 401k membership
Total participants, beginning-of-year 2019-06-01 114
Total number of active participants reported on line 7a of the Form 5500 2019-06-01 110
Number of retired or separated participants receiving benefits 2019-06-01 0
Number of other retired or separated participants entitled to future benefits 2019-06-01 0
Total of all active and inactive participants 2019-06-01 110
Number of employers contributing to the scheme 2019-06-01 0

Measure	Date	Value
2021: VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN 2021 401k membership
Total participants, beginning-of-year	2021-06-01	131
Total number of active participants reported on line 7a of the Form 5500	2021-06-01	0
Number of retired or separated participants receiving benefits	2021-06-01	0
Number of other retired or separated participants entitled to future benefits	2021-06-01	0
Total of all active and inactive participants	2021-06-01	0
2020: VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN 2020 401k membership
Total participants, beginning-of-year	2020-06-01	110
Total number of active participants reported on line 7a of the Form 5500	2020-06-01	86
Number of retired or separated participants receiving benefits	2020-06-01	6
Number of other retired or separated participants entitled to future benefits	2020-06-01	0
Total of all active and inactive participants	2020-06-01	92
Number of employers contributing to the scheme	2020-06-01	0
2019: VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN 2019 401k membership
Total participants, beginning-of-year	2019-06-01	114
Total number of active participants reported on line 7a of the Form 5500	2019-06-01	110
Number of retired or separated participants receiving benefits	2019-06-01	0
Number of other retired or separated participants entitled to future benefits	2019-06-01	0
Total of all active and inactive participants	2019-06-01	110
Number of employers contributing to the scheme	2019-06-01	0

Form 5500 Responses for VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN

2021: VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN 2021 form 5500 responses
2021-06-01	Type of plan entity	Single employer plan
2021-06-01	Submission has been amended	No
2021-06-01	This submission is the final filing	Yes
2021-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-06-01	Plan is a collectively bargained plan	No
2021-06-01	Plan funding arrangement – Insurance	Yes
2021-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2021-06-01	Plan benefit arrangement – Insurance	Yes
2021-06-01	Plan benefit arrangement – General assets of the sponsor	Yes
2020: VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN 2020 form 5500 responses
2020-06-01	Type of plan entity	Single employer plan
2020-06-01	Plan funding arrangement – Insurance	Yes
2020-06-01	Plan benefit arrangement – Insurance	Yes
2019: VISTRA INTERNATIONAL EXPANSION USA INC. MEDICAL AND DENTAL PLAN 2019 form 5500 responses
2019-06-01	Type of plan entity	Single employer plan
2019-06-01	First time form 5500 has been submitted	Yes
2019-06-01	Plan funding arrangement – Insurance	Yes
2019-06-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

8036476

Policy instance

Insurance contract or identification number	8036476
Number of Individuals Covered	187
Insurance policy start date	2021-06-01
Insurance policy end date	2022-05-31
Total amount of commissions paid to insurance broker	USD $49,506
Total amount of fees paid to insurance company	USD $7,974
Are there contracts with allocated funds for individual policies?	0
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	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
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 $1,262,400
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $36,667
Amount paid for insurance broker fees	7974
Additional information about fees paid to insurance broker	OTHER COMMISSION
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

8036476

Policy instance

Insurance contract or identification number	8036476
Number of Individuals Covered	182
Insurance policy start date	2020-06-01
Insurance policy end date	2021-05-31
Total amount of commissions paid to insurance broker	USD $64,385
Total amount of fees paid to insurance company	USD $9,043
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,661,514
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $64,385
Amount paid for insurance broker fees	9043
Additional information about fees paid to insurance broker	OTHER COMMISSION
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

8036476

Policy instance

Insurance contract or identification number	8036476
Number of Individuals Covered	249
Insurance policy start date	2019-06-01
Insurance policy end date	2020-05-31
Total amount of commissions paid to insurance broker	USD $56,439
Total amount of fees paid to insurance company	USD $12,075
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?	Yes
Commission paid to Insurance Broker	USD $56,439
Amount paid for insurance broker fees	12075
Additional information about fees paid to insurance broker	OTHER COMMISSION
Insurance broker organization code?	3

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Company Name:	VISTRA INTERNATIONAL EXPANSION (USA), INC.
Employer identification number (EIN):	900599705
NAIC Classification:	541600