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PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN 401k Plan overview

Plan NamePRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN
Plan identification number 501

PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision

401k Sponsoring company profile

PRO-FORM MANUFACTURING LLC DBA PRO-FORM LABORATORIES has sponsored the creation of one or more 401k plans.

Company Name:PRO-FORM MANUFACTURING LLC DBA PRO-FORM LABORATORIES
Employer identification number (EIN):943237141
NAIC Classification:424400

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012017-06-01JEFF MITCHELL
5012016-06-01JEFF MITCHELL
5012015-06-01DAVID HENDRICKSON

Plan Statistics for PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN

401k plan membership statisitcs for PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN

Measure Date Value
2017: PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN 2017 401k membership
Total participants, beginning-of-year2017-06-01157
Total number of active participants reported on line 7a of the Form 55002017-06-01177
Number of retired or separated participants receiving benefits2017-06-012
Number of other retired or separated participants entitled to future benefits2017-06-010
Total of all active and inactive participants2017-06-01179
2016: PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN 2016 401k membership
Total participants, beginning-of-year2016-06-01151
Total number of active participants reported on line 7a of the Form 55002016-06-01173
Number of retired or separated participants receiving benefits2016-06-010
Number of other retired or separated participants entitled to future benefits2016-06-010
Total of all active and inactive participants2016-06-01173
2015: PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN 2015 401k membership
Total participants, beginning-of-year2015-06-01132
Total number of active participants reported on line 7a of the Form 55002015-06-01146
Number of retired or separated participants receiving benefits2015-06-012
Number of other retired or separated participants entitled to future benefits2015-06-010
Total of all active and inactive participants2015-06-01148

Form 5500 Responses for PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN

2017: PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN 2017 form 5500 responses
2017-06-01Type of plan entitySingle employer plan
2017-06-01Submission has been amendedNo
2017-06-01This submission is the final filingNo
2017-06-01This return/report is a short plan year return/report (less than 12 months)No
2017-06-01Plan is a collectively bargained planNo
2017-06-01Plan funding arrangement – InsuranceYes
2017-06-01Plan benefit arrangement – InsuranceYes
2016: PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN 2016 form 5500 responses
2016-06-01Type of plan entitySingle employer plan
2016-06-01Submission has been amendedNo
2016-06-01This submission is the final filingNo
2016-06-01This return/report is a short plan year return/report (less than 12 months)No
2016-06-01Plan is a collectively bargained planNo
2016-06-01Plan funding arrangement – InsuranceYes
2016-06-01Plan benefit arrangement – InsuranceYes
2015: PRO-FORM LABORATORIES MEDICAL, DENTAL, VISION, LIFE AND AD&D PLAN 2015 form 5500 responses
2015-06-01Type of plan entitySingle employer plan
2015-06-01First time form 5500 has been submittedYes
2015-06-01Submission has been amendedNo
2015-06-01This submission is the final filingNo
2015-06-01This return/report is a short plan year return/report (less than 12 months)No
2015-06-01Plan is a collectively bargained planNo
2015-06-01Plan funding arrangement – InsuranceYes
2015-06-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )
Policy contract number706937
Policy instance 1
Insurance contract or identification number706937
Number of Individuals Covered202
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $53,829
Total amount of fees paid to insurance companyUSD $4
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $1,061,988
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $53,829
Amount paid for insurance broker fees4
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number874546G
Policy instance 2
Insurance contract or identification number874546G
Number of Individuals Covered188
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $2,753
Total amount of fees paid to insurance companyUSD $0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH & DISMEMBERMENT
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 CarrierUSD $13,764
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $2,753
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
UNITED CONCORDIA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 85766 )
Policy contract number907167-000,099
Policy instance 3
Insurance contract or identification number907167-000,099
Number of Individuals Covered188
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $9,048
Total amount of fees paid to insurance companyUSD $397
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $98,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $9,048
Amount paid for insurance broker fees397
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. (National Association of Insurance Commissioners NAIC id number: 95789 )
Policy contract number907167-001,199
Policy instance 4
Insurance contract or identification number907167-001,199
Number of Individuals Covered113
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,212
Total amount of fees paid to insurance companyUSD $52
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $13,521
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,212
Amount paid for insurance broker fees52
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES
VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number30049029
Policy instance 5
Insurance contract or identification number30049029
Number of Individuals Covered105
Insurance policy start date2017-06-01
Insurance policy end date2018-05-31
Total amount of commissions paid to insurance brokerUSD $1,153
Total amount of fees paid to insurance companyUSD $0
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
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 CarrierUSD $21,580
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,153
Insurance broker organization code?3
Insurance broker nameCBIZ BENEFITS & INSURANCE SERVICES

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