Receipt Confirmation Code: 00011386-2045

2018 Form M-1

MEWA-ECE Form

This Form is Open to Public Inspection

Report for Multiple Employer Welfare Arrangements (MEWAs) and Certain Entities Claiming Exception (ECEs)
This filing is required to be filed under section 101(g) of the Employee Retirement Income Security Act of 1974, as amended by the Patient Protection and Affordable Care Act.

OMB No. 1210-0116

Department of Labor
Employee Benefits Security Administration

PART I
PURPOSE OF FILING

Complete as applicable:

A
(1) Annual Report:
  • Calendar Year
  • or the fiscal year beginning and ending
(2) MEWA Registration
(3) ECE Origination
(4) ECE Special Filing
B
Check here if this is a final report
Check here if this is an amended report
Check here if this is a Request for an extension
C
Identify the type of entity:
(1) A Plan MEWA
(2) A Non-Plan MEWA
(3) An Entity Claiming Exception (ECE)
D
Enter the most recent date the MEWA or ECE filed the Form M-1:
Check the box if this is the first filing or enter the date below: 01/14/2022

PART II
CUSTODIAL & FINANCIAL INFORMATION

1a
Name and address of the MEWA or ECE
Zingerman's Delicatessen

3756 Plaza Dr.

Ann Arbor, MI 48108
1b
Telephone number of the MEWA or ECE (734) 668-4662
1c
Employer Identification Number (EIN) 38-2409230
1d
Plan Number (PN)
2a
Name and address of the administrator of the MEWA or ECE
Kimberly Simoneau

3756 Plaza Dr.

Ann Arbor, MI 48108
2b
Telephone number of the administrator (734) 668-4662
2c
EIN
2d
E-mail address of the administrator
ksimoneau@zingermans.com
3a
Name and address of the entity or entities sponsoring the MEWA or ECE
Zingerman's Delicatessen

3756 Plaza Dr.

Ann Arbor, MI 48108
3b
Telephone number of the sponsor (734) 668-4662
3c
EIN 38-2409230
4a
Name and address of the agent for service of process or registered agent
Hylant Group

24 Frank Lloyd Wright Dr. Ste J4100

Ann Arbor, MI 48105
4b
Telephone number of such person (734) 741-0044
4c
E-mail address of such person
5a
Name and address of each member of the Board, officer, trustee, or custodian of the MEWA or ECE
Paul Saginaw

3756 Plaza Dr.

Ann Arbor, MI 48108
5b
Telephone number of each such person (734) 668-4662
5c
E-mail address of such person
psaginaw@zingermans.com
5a
Name and address of each member of the Board, officer, trustee, or custodian of the MEWA or ECE
5b
Telephone number of each such person
5c
E-mail address of such person
5a
Name and address of each member of the Board, officer, trustee, or custodian of the MEWA or ECE
Aron Weinzweig

3756 Plaza Dr.

Ann Arbor, MI 48108
5b
Telephone number of each such person (734) 668-4662
5c
E-mail address of such person
aweinzweig@zingermans.com
6a
Name and address of all promoters and/or agents responsible for marketing the MEWA or ECE
6b
Telephone number of each promoter or agent
6c
E-mail address of such person
6d
EIN of each promotor or agent
7a
Name and address of any person, financial institution(s), or other entity holding assets for the MEWA or ECE
Old National Bank

2723 S. State St.

Ann Arbor, MI 48104
7b
Telephone Number of person, financial institution, or entity (734) 887-2600
7a
Name and address of any person, financial institution(s), or other entity holding assets for the MEWA or ECE
7b
Telephone Number of person, financial institution, or entity
7a
Name and address of any person, financial institution(s), or other entity holding assets for the MEWA or ECE
Level One Bank

125 W. William St. #1328

Ann Arbor, MI 48104
7b
Telephone Number of person, financial institution, or entity (734) 761-1475
8a
Name and address of any actuary(ies) providing services to the MEWA or ECE
8b
Telephone number of each actuary
8c
E-mail address of each actuary
8d
EIN of each actuary
9a
If the MEWA or ECE has a contract with a third party administrator (TPA) the name and address of the third party administrator(s)
9b
Telephone number of each TPA
9c
E-mail address of each TPA
9d
EIN of each TPA
10a
Name and address of any person or entity that has authority or control over the MEWA's or ECE's assets or over assets paid to the entity by plans or employers for the provision of benefits
10b
Telephone number of each such person or entity
10c
E-mail address of such person or entity
10d
EIN of each such person or entity
11a
Name and address of any person or entity that has discretionary authority, control, or responsibility with respect to the administration of the MEWA or ECE or any benefit program offered by it
Zingerman's Service Network

3756 Plaza Dr.

Ann Arbor, MI 48108
11b
Telephone number of each such person or entity (734) 668-4662
11c
E-mail address of such person or entity
d4p@zingermans.com
11d
EIN of each such person or entity 38-3188388
12a
Names and addresses of the MEWAs or ECEs that merged
12b
Telephone number of the entities
12c
EINs
12d
PNs
13
Do you have an opinion from an actuary assessing the MEWA's or ECE's actuarial soundness, including the adequacy of contribution rates? No
14a
Are you, your entity, and/or its officers, directors, and employees covered by fiduciary liability policies? Please identify the carrier that issued the fiduciary liability policy(ies) in the space provided. Yes CNA
14b
Are the fiduciaries of each of the plans whose participants are receiving benefits from the entity covered by a fiduciary liability policy? Yes
15
Are all assets in the possession of the MEWA or ECE maintained consistent with section 403 of ERISA and 29 CFR 2550.403a-1 and 2550.403b-1? Yes If no, please explain.
16a
Within the past five years, has any litigation or other enforcement proceeding (including any administrative proceeding) regarding any MEWA, ECE, or Group Health Plan been instituted by a Federal or State agency against the MEWA or ECE, a trustee, or a director, owner, partner, senior manager, or officer of the sponsoring entity? No If yes, please identify each litigation or enforcement proceeding to include (if applicable): (1) the case number, (2) the date, (3) the nature of the proceedings, (4) the court, (5) all parties (for example, plaintiffs and defendants or petitioners and respondents), and (6) the disposition.
16b
Have any of the persons or entities listed in this Part II ever been the subject of any criminal or civil investigation or action involving dishonesty or breach of trust or been convicted of a felony? No If yes, please explain.
16c
Have any cease and desist orders been issued by a Federal or State agency against any of the entities listed in this Part II? No
Entity Year
17
Complete the following chart:
17a 17b 17c 17d 17e 17f 17g 17h 17i 17j
Enter all States where the MEWA or ECE is operating. Is coverage provided? State registration number. Name of state agent or entity for service of process. Is the entity a licensed health insurer in this State? If yes to 17e, enter NAIC number. If no to 17e, is the entity fully insured? If yes to 17g, enter name and NAIC number of insurer. Does the entity purchase stop loss coverage? If yes to 17i, enter the name and NAIC number of insurer.
MI
Is new? 		Yes No Yes Priority Health - 95561 No
18
Of the States identified in box 17a, identify those States in which the entity conducted 20 percent or more of its business (based on the number of participants receiving coverage for medical care). MI
19
Total number of participants covered under the entity. 540

PART III
INFORMATION FOR COMPLIANCE WITH PART 7 OF ERISA

20
If you answered yes to box 16a, in reference to any State or Federal litigation or other enforcement proceeding (including any administrative proceeding), check yes below if the allegation concerns a provision under part 7 of ERISA, a corresponding provision under the Internal Revenue Code or Public Health Service Act, a breach of any duty under Title I of ERISA if the underlying violation relates to a requirement under part 7 of ERISA, or a breach of a contractual obligation if the contract provision relates to a requirement under part 7 of ERISA. N/A
21
Is the MEWA subject to part 7 of ERISA on the date of the filing? (Note: The Self-Compliance Tool at <a href="http://www.dol.gov/ebsa/pdf/cagappa.pdf">www.dol.gov/ebsa/pdf/cagappa.pdf</a> may be helpful in answering Boxes 21-21f.) If "yes," complete the following. Yes
21a
Is the coverage provided by the MEWA or ECE in compliance with the portability and nondiscrimination provisions of the Health Insurance Portability and Accountability Act of 1996, including Title I of the Genetic Information Nondiscrimination Act of 2008, and the Department of Labor's (Department's) regulations issued thereunder? Yes
21b
Is the coverage provided by the MEWA or ECE in compliance with the Mental Health Parity Act of 1996 and the Mental Health Parity and Addiction Equity Act of 2008 and the Department's regulations issued thereunder? Yes
21c
Is the coverage provided by the MEWA or ECE in compliance with the Newborns' and Mothers' Health Protection Act of 1996 and the Department's regulations issued thereunder? Yes
21d
Is the coverage provided by the MEWA or ECE in compliance with the Women's Health and Cancer Rights Act of 1998? Yes
21e
Is the coverage provided by the MEWA or ECE in compliance with Michelle's Law? Yes
21f
Is the coverage provided by the MEWA or ECE in compliance with the Patient Protection and Affordable Care Act of 2010 and the Department's regulations issued thereunder that are applicable as of the date signed at the bottom of this form? Yes

ATTACHMENTS

SIGNATURE

Under penalty of perjury and other penalties set forth in the instructions, I declare that I have examined this report, including any accompanying attachments, and to the best of my knowledge and belief, it is true and correct. Under penalty of perjury and other penalties set forth in the instructions, I also declare that, unless this is an extension request, this report is complete.