Form M-1 - Report For Multiple Employer Welfare Arrangements (Mewas) And Certain Entities Claiming Exception (Eces) - Department Of Labor 2012
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32012
Report for Multiple Employer Welfare
OMB No. 1210-0116
Arrangements (MEWAs) and Certain
Form M-1
Entities Claiming Exception (ECEs)
Department of Labor
MEWA-ECE Form
This filing is required to be filed under section 101(g) of the
Employee Benefits
Employee Retirement Income Security Act of 1974, as amended
This Form is Open to
by the Patient Protection and Affordable Care Act.
Security Administration
Public Inspection
PART I
PURPOSE OF FILING
Complete as applicable:
A Identify the type of filing:
C Identify the type of entity:
(1)
Annual Report:
(1)
A Plan MEWA
Calendar Year; or
(2)
A Non-Plan MEWA
Fiscal Year beginning
(3)
An Entity Claiming Exception (ECE)
and ending
D Enter the most recent date the MEWA or ECE filed the
(2)
Registration
(3)
Origination
Form M-1:
(4)
Special Filing
Check the box if this is the first filing or enter the date below.
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
PART II
CUSTODIAL & FINANCIAL INFORMATION
1a
Name and address of the MEWA or ECE
1b
Telephone number of the MEWA or ECE
1c
Employer Identification Number (EIN)
1d
Plan Number (PN)
2a
2b
Name and address of the administrator of the MEWA or ECE
Telephone number of the administrator
2c
EIN
2d
E-mail address of the administrator
3a
3b
Name and address of the entity or entities sponsoring the MEWA or ECE
Telephone number of the sponsor
3c
EIN
4a
Name and address of the agent for service of process or registered agent 4b
Telephone number of such person
4c
E-mail address of such person
5a
5b
Name and address of each member of the Board, officer, trustee, or
Telephone number of each such person
custodian of the MEWA or ECE
5c
E-mail address of such person
6a
Name and address of all promoters and/or agents responsible for
6b
Telephone number of each promoter or agent
marketing the MEWA or ECE
6c
E-mail address of such person
6d
EIN of each promoter or agent
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