401k Plan data: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN plan

HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 401k Plan overview

Plan Name	HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN
Plan identification number	001

HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Plan provides for automatic enrollment in plan that has employee contributions deducted from payroll.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

HOMETOWN URGENT CARE has sponsored the creation of one or more 401k plans.

Company Name: HOMETOWN URGENT CARE

Employer identification number (EIN): 454745431

NAIC Classification: 621610
NAIC Description: Home Health Care Services

Form 5500 Filing Information

Submission information for form 5500 for 401k plan HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2016-01-01 CHRIS HALE CHRIS HALE 2017-04-13
001 2015-01-01 CHRIS HALE CHRIS HALE 2016-10-14
001 2014-01-01 CHRIS HALE CHRIS HALE 2015-10-15
001 2013-01-01 CHRIS HALE CHRIS HALE 2015-01-27
001 2012-07-01 ANNA CAMERON ANNA CAMERON 2013-07-22

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
001	2016-01-01	CHRIS HALE	CHRIS HALE	2017-04-13
001	2015-01-01	CHRIS HALE	CHRIS HALE	2016-10-14
001	2014-01-01	CHRIS HALE	CHRIS HALE	2015-10-15
001	2013-01-01	CHRIS HALE	CHRIS HALE	2015-01-27
001	2012-07-01	ANNA CAMERON	ANNA CAMERON	2013-07-22

Plan Statistics for HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN

401k plan membership statisitcs for HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN

Measure Date Value
2016: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 193
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 0
Number of participants with account balances 2016-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 0
2015: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 217
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 164
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 23
Total of all active and inactive participants 2015-01-01 187
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 187
Number of participants with account balances 2015-01-01 142
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 253
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 177
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 25
Total of all active and inactive participants 2014-01-01 202
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 202
Number of participants with account balances 2014-01-01 159
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 305
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 219
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 31
Total of all active and inactive participants 2013-01-01 250
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 1
Total participants 2013-01-01 251
Number of participants with account balances 2013-01-01 213
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 149
2012: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-07-01 269
Total number of active participants reported on line 7a of the Form 5500 2012-07-01 276
Number of retired or separated participants receiving benefits 2012-07-01 0
Number of other retired or separated participants entitled to future benefits 2012-07-01 23
Total of all active and inactive participants 2012-07-01 299
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-07-01 0
Total participants 2012-07-01 299
Number of participants with account balances 2012-07-01 263
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-07-01 54

Measure	Date	Value
2016: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	193
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	0
Number of participants with account balances	2016-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	0
2015: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	217
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	164
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	23
Total of all active and inactive participants	2015-01-01	187
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	187
Number of participants with account balances	2015-01-01	142
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	253
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	177
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	25
Total of all active and inactive participants	2014-01-01	202
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	202
Number of participants with account balances	2014-01-01	159
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	305
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	219
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	31
Total of all active and inactive participants	2013-01-01	250
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	1
Total participants	2013-01-01	251
Number of participants with account balances	2013-01-01	213
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	149
2012: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-07-01	269
Total number of active participants reported on line 7a of the Form 5500	2012-07-01	276
Number of retired or separated participants receiving benefits	2012-07-01	0
Number of other retired or separated participants entitled to future benefits	2012-07-01	23
Total of all active and inactive participants	2012-07-01	299
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-07-01	0
Total participants	2012-07-01	299
Number of participants with account balances	2012-07-01	263
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-07-01	54

Financial Data on HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN

Measure	Date	Value
2016 : HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2016 401k financial data
Unrealized appreciation/depreciation of real estate assets	2016-06-21	$0
Unrealized appreciation/depreciation of other (non real estate) assets	2016-06-21	$0
Total unrealized appreciation/depreciation of assets	2016-06-21	$0
Total transfer of assets to this plan	2016-06-21	$0
Total transfer of assets from this plan	2016-06-21	$1,050,922
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-06-21	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-06-21	$0
Total income from all sources (including contributions)	2016-06-21	$112,813
Total loss/gain on sale of assets	2016-06-21	$0
Total of all expenses incurred	2016-06-21	$188,318
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-06-21	$182,943
Value of total corrective distributions	2016-06-21	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-06-21	$79,428
Value of total assets at end of year	2016-06-21	$0
Value of total assets at beginning of year	2016-06-21	$1,126,427
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-06-21	$5,375
Total income from rents	2016-06-21	$0
Total interest from all sources	2016-06-21	$114
Total dividends received (eg from common stock, registered investment company shares)	2016-06-21	$1,070
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-06-21	No
Total dividends received from registered investment company shares (eg mutual funds)	2016-06-21	$1,070
Administrative expenses professional fees incurred	2016-06-21	$0
Was this plan covered by a fidelity bond	2016-06-21	Yes
Value of fidelity bond cover	2016-06-21	$300,000
If this is an individual account plan, was there a blackout period	2016-06-21	Yes
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-06-21	$0
Were there any nonexempt tranactions with any party-in-interest	2016-06-21	No
Amount of non-exempt transactions with any party-in-interest	2016-06-21	$0
Contributions received from participants	2016-06-21	$59,970
Participant contributions at end of year	2016-06-21	$0
Participant contributions at beginning of year	2016-06-21	$0
Income. Received or receivable in cash from other sources (including rollovers)	2016-06-21	$19,458
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2016-06-21	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2016-06-21	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2016-06-21	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2016-06-21	$0
Other income not declared elsewhere	2016-06-21	$0
Administrative expenses (other) incurred	2016-06-21	$0
Liabilities. Value of operating payables at beginning of year	2016-06-21	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-06-21	No
Value of net income/loss	2016-06-21	$-75,505
Value of net assets at end of year (total assets less liabilities)	2016-06-21	$0
Value of net assets at beginning of year (total assets less liabilities)	2016-06-21	$1,126,427
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-06-21	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-06-21	No
Amount of loans by the plan or fixed income obligations due to the plan which were in default/classified-as-uncollectible as of the close of the plan year	2016-06-21	$0
Were any leases to which the plan was party in default or uncollectible	2016-06-21	No
Amount of leases to which the plan was a party which were in default/classified-as-uncollectible during the year	2016-06-21	$0
Investment advisory and management fees	2016-06-21	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2016-06-21	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2016-06-21	$129,022
Value of interest in pooled separate accounts at end of year	2016-06-21	$0
Value of interest in pooled separate accounts at beginning of year	2016-06-21	$79,177
Income. Interest from loans (other than to participants)	2016-06-21	$0
Interest earned on other investments	2016-06-21	$114
Income. Interest from US Government securities	2016-06-21	$0
Income. Interest from corporate debt instruments	2016-06-21	$0
Value of interest in common/collective trusts at end of year	2016-06-21	$0
Value of interest in common/collective trusts at beginning of year	2016-06-21	$895,570
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2016-06-21	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2016-06-21	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2016-06-21	$22,658
Expenses. Payments to insurance carriers foe the provision of benefits	2016-06-21	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2016-06-21	$2,487
Net investment gain/loss from pooled separate accounts	2016-06-21	$218
Net investment gain or loss from common/collective trusts	2016-06-21	$29,496
Net gain/loss from 103.12 investment entities	2016-06-21	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-06-21	No
Was there a failure to transmit to the plan any participant contributions	2016-06-21	No
Has the plan failed to provide any benefit when due under the plan	2016-06-21	No
Contributions received in cash from employer	2016-06-21	$0
Employer contributions (assets) at end of year	2016-06-21	$0
Employer contributions (assets) at beginning of year	2016-06-21	$0
Income. Dividends from preferred stock	2016-06-21	$0
Income. Dividends from common stock	2016-06-21	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-06-21	$182,943
Contract administrator fees	2016-06-21	$5,375
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2016-06-21	Yes
Liabilities. Value of benefit claims payable at beginning of year	2016-06-21	$0
Did the plan have assets held for investment	2016-06-21	No
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-06-21	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-06-21	Yes
Aggregate proceeds on sale of assets	2016-06-21	$0
Aggregate carrying amount (costs) on sale of assets	2016-06-21	$0
Liabilities. Value of acquisition indebtedness at beginning of year	2016-06-21	$0
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-06-21	Yes
Opinion of an independent qualified public accountant for this plan	2016-06-21	Disclaimer
Accountancy firm name	2016-06-21	SWINDON SPRINGER & CO. INC
Accountancy firm EIN	2016-06-21	311339842
2015 : HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2015 401k financial data
Unrealized appreciation/depreciation of real estate assets	2015-12-31	$0
Unrealized appreciation/depreciation of other (non real estate) assets	2015-12-31	$0
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total transfer of assets to this plan	2015-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total income from all sources (including contributions)	2015-12-31	$354,938
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$516,987
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$504,737
Value of total corrective distributions	2015-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$368,971
Value of total assets at end of year	2015-12-31	$1,126,427
Value of total assets at beginning of year	2015-12-31	$1,288,476
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$12,250
Total income from rents	2015-12-31	$0
Total interest from all sources	2015-12-31	$449
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$1,705
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2015-12-31	$1,705
Administrative expenses professional fees incurred	2015-12-31	$0
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$300,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Amount of non-exempt transactions with any party-in-interest	2015-12-31	$0
Contributions received from participants	2015-12-31	$368,971
Participant contributions at end of year	2015-12-31	$0
Participant contributions at beginning of year	2015-12-31	$11,963
Income. Received or receivable in cash from other sources (including rollovers)	2015-12-31	$0
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2015-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2015-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2015-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2015-12-31	$0
Other income not declared elsewhere	2015-12-31	$0
Administrative expenses (other) incurred	2015-12-31	$0
Liabilities. Value of operating payables at beginning of year	2015-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$-162,049
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$1,126,427
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$1,288,476
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Amount of loans by the plan or fixed income obligations due to the plan which were in default/classified-as-uncollectible as of the close of the plan year	2015-12-31	$0
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Amount of leases to which the plan was a party which were in default/classified-as-uncollectible during the year	2015-12-31	$0
Investment advisory and management fees	2015-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2015-12-31	$129,022
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$90,539
Value of interest in pooled separate accounts at end of year	2015-12-31	$79,177
Value of interest in pooled separate accounts at beginning of year	2015-12-31	$94,228
Income. Interest from loans (other than to participants)	2015-12-31	$0
Interest earned on other investments	2015-12-31	$449
Income. Interest from US Government securities	2015-12-31	$0
Income. Interest from corporate debt instruments	2015-12-31	$0
Value of interest in common/collective trusts at end of year	2015-12-31	$895,570
Value of interest in common/collective trusts at beginning of year	2015-12-31	$1,053,057
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2015-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-12-31	$22,658
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$38,689
Expenses. Payments to insurance carriers foe the provision of benefits	2015-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$-7,139
Net investment gain/loss from pooled separate accounts	2015-12-31	$198
Net investment gain or loss from common/collective trusts	2015-12-31	$-9,246
Net gain/loss from 103.12 investment entities	2015-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	No
Was there a failure to transmit to the plan any participant contributions	2015-12-31	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$0
Employer contributions (assets) at end of year	2015-12-31	$0
Employer contributions (assets) at beginning of year	2015-12-31	$0
Income. Dividends from preferred stock	2015-12-31	$0
Income. Dividends from common stock	2015-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$504,737
Contract administrator fees	2015-12-31	$12,250
Liabilities. Value of benefit claims payable at beginning of year	2015-12-31	$0
Did the plan have assets held for investment	2015-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Aggregate proceeds on sale of assets	2015-12-31	$0
Aggregate carrying amount (costs) on sale of assets	2015-12-31	$0
Liabilities. Value of acquisition indebtedness at beginning of year	2015-12-31	$0
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	SWINDON SPRINGER & CO. INC.
Accountancy firm EIN	2015-12-31	311339842
2014 : HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2014 401k financial data
Unrealized appreciation/depreciation of real estate assets	2014-12-31	$0
Unrealized appreciation/depreciation of other (non real estate) assets	2014-12-31	$0
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total transfer of assets to this plan	2014-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total income from all sources (including contributions)	2014-12-31	$497,263
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$381,471
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$369,104
Value of total corrective distributions	2014-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$424,001
Value of total assets at end of year	2014-12-31	$1,288,476
Value of total assets at beginning of year	2014-12-31	$1,172,684
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$12,367
Total income from rents	2014-12-31	$0
Total interest from all sources	2014-12-31	$571
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$898
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2014-12-31	$898
Administrative expenses professional fees incurred	2014-12-31	$0
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$300,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Amount of non-exempt transactions with any party-in-interest	2014-12-31	$0
Contributions received from participants	2014-12-31	$383,667
Participant contributions at end of year	2014-12-31	$11,963
Participant contributions at beginning of year	2014-12-31	$12,476
Income. Received or receivable in cash from other sources (including rollovers)	2014-12-31	$40,334
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2014-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2014-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2014-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2014-12-31	$0
Other income not declared elsewhere	2014-12-31	$0
Administrative expenses (other) incurred	2014-12-31	$0
Liabilities. Value of operating payables at beginning of year	2014-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$115,792
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$1,288,476
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$1,172,684
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Amount of loans by the plan or fixed income obligations due to the plan which were in default/classified-as-uncollectible as of the close of the plan year	2014-12-31	$0
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Amount of leases to which the plan was a party which were in default/classified-as-uncollectible during the year	2014-12-31	$0
Investment advisory and management fees	2014-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2014-12-31	$90,539
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2014-12-31	$154,110
Value of interest in pooled separate accounts at end of year	2014-12-31	$94,228
Value of interest in pooled separate accounts at beginning of year	2014-12-31	$90,445
Income. Interest from loans (other than to participants)	2014-12-31	$0
Interest earned on other investments	2014-12-31	$571
Income. Interest from US Government securities	2014-12-31	$0
Income. Interest from corporate debt instruments	2014-12-31	$0
Value of interest in common/collective trusts at end of year	2014-12-31	$1,053,057
Value of interest in common/collective trusts at beginning of year	2014-12-31	$886,719
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2014-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$38,689
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$28,934
Expenses. Payments to insurance carriers foe the provision of benefits	2014-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$2,137
Net investment gain/loss from pooled separate accounts	2014-12-31	$11,659
Net investment gain or loss from common/collective trusts	2014-12-31	$57,997
Net gain/loss from 103.12 investment entities	2014-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	No
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$0
Employer contributions (assets) at end of year	2014-12-31	$0
Employer contributions (assets) at beginning of year	2014-12-31	$0
Income. Dividends from preferred stock	2014-12-31	$0
Income. Dividends from common stock	2014-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$369,104
Contract administrator fees	2014-12-31	$12,367
Liabilities. Value of benefit claims payable at beginning of year	2014-12-31	$0
Did the plan have assets held for investment	2014-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Aggregate proceeds on sale of assets	2014-12-31	$0
Aggregate carrying amount (costs) on sale of assets	2014-12-31	$0
Liabilities. Value of acquisition indebtedness at beginning of year	2014-12-31	$0
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	SWINDON SPRINGER & CO., INC
Accountancy firm EIN	2014-12-31	311339842
2013 : HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2013 401k financial data
Unrealized appreciation/depreciation of real estate assets	2013-12-31	$0
Unrealized appreciation/depreciation of other (non real estate) assets	2013-12-31	$0
Total unrealized appreciation/depreciation of assets	2013-12-31	$0
Total transfer of assets to this plan	2013-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total income from all sources (including contributions)	2013-12-31	$800,107
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$190,800
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$179,538
Value of total corrective distributions	2013-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$643,184
Value of total assets at end of year	2013-12-31	$1,172,684
Value of total assets at beginning of year	2013-12-31	$563,377
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$11,262
Total income from rents	2013-12-31	$0
Total interest from all sources	2013-12-31	$338
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$2,585
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2013-12-31	$2,585
Administrative expenses professional fees incurred	2013-12-31	$0
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2013-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Amount of non-exempt transactions with any party-in-interest	2013-12-31	$0
Contributions received from participants	2013-12-31	$551,773
Participant contributions at end of year	2013-12-31	$12,476
Participant contributions at beginning of year	2013-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2013-12-31	$91,411
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2013-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2013-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2013-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2013-12-31	$0
Other income not declared elsewhere	2013-12-31	$0
Administrative expenses (other) incurred	2013-12-31	$0
Liabilities. Value of operating payables at beginning of year	2013-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$609,307
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$1,172,684
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$563,377
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Amount of loans by the plan or fixed income obligations due to the plan which were in default/classified-as-uncollectible as of the close of the plan year	2013-12-31	$0
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Amount of leases to which the plan was a party which were in default/classified-as-uncollectible during the year	2013-12-31	$0
Investment advisory and management fees	2013-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2013-12-31	$154,110
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2013-12-31	$54,344
Value of interest in pooled separate accounts at end of year	2013-12-31	$90,445
Value of interest in pooled separate accounts at beginning of year	2013-12-31	$42,226
Income. Interest from loans (other than to participants)	2013-12-31	$0
Interest earned on other investments	2013-12-31	$338
Income. Interest from US Government securities	2013-12-31	$0
Income. Interest from corporate debt instruments	2013-12-31	$0
Value of interest in common/collective trusts at end of year	2013-12-31	$886,719
Value of interest in common/collective trusts at beginning of year	2013-12-31	$432,062
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2013-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$28,934
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$34,745
Expenses. Payments to insurance carriers foe the provision of benefits	2013-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2013-12-31	$11,421
Net investment gain/loss from pooled separate accounts	2013-12-31	$22,862
Net investment gain or loss from common/collective trusts	2013-12-31	$119,717
Net gain/loss from 103.12 investment entities	2013-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	No
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Contributions received in cash from employer	2013-12-31	$0
Employer contributions (assets) at end of year	2013-12-31	$0
Employer contributions (assets) at beginning of year	2013-12-31	$0
Income. Dividends from preferred stock	2013-12-31	$0
Income. Dividends from common stock	2013-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$179,538
Contract administrator fees	2013-12-31	$11,262
Liabilities. Value of benefit claims payable at beginning of year	2013-12-31	$0
Did the plan have assets held for investment	2013-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Aggregate proceeds on sale of assets	2013-12-31	$0
Aggregate carrying amount (costs) on sale of assets	2013-12-31	$0
Liabilities. Value of acquisition indebtedness at beginning of year	2013-12-31	$0
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2013-12-31	Disclaimer
Accountancy firm name	2013-12-31	SWINDON, SPRINGER & CO., INC.
Accountancy firm EIN	2013-12-31	311339842
2012 : HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2012 401k financial data
Unrealized appreciation/depreciation of real estate assets	2012-12-31	$0
Unrealized appreciation/depreciation of other (non real estate) assets	2012-12-31	$0
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total transfer of assets to this plan	2012-12-31	$0
Total transfer of assets from this plan	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total income from all sources (including contributions)	2012-12-31	$568,933
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$5,556
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$3,123
Value of total corrective distributions	2012-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$556,332
Value of total assets at end of year	2012-12-31	$563,377
Value of total assets at beginning of year	2012-12-31	$0
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$2,433
Total income from rents	2012-12-31	$0
Total interest from all sources	2012-12-31	$147
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$269
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2012-12-31	$269
Administrative expenses professional fees incurred	2012-12-31	$0
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$1,000,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Amount of non-exempt transactions with any party-in-interest	2012-12-31	$0
Contributions received from participants	2012-12-31	$235,921
Participant contributions at end of year	2012-12-31	$0
Participant contributions at beginning of year	2012-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2012-12-31	$320,411
Expenses. Other payments made (not to insurance carriers or or participants/beneficiaries)	2012-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2012-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2012-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2012-12-31	$0
Other income not declared elsewhere	2012-12-31	$0
Administrative expenses (other) incurred	2012-12-31	$0
Liabilities. Value of operating payables at beginning of year	2012-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$563,377
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$563,377
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Amount of loans by the plan or fixed income obligations due to the plan which were in default/classified-as-uncollectible as of the close of the plan year	2012-12-31	$0
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Amount of leases to which the plan was a party which were in default/classified-as-uncollectible during the year	2012-12-31	$0
Investment advisory and management fees	2012-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at end of year	2012-12-31	$54,344
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-12-31	$0
Value of interest in pooled separate accounts at end of year	2012-12-31	$42,226
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$0
Income. Interest from loans (other than to participants)	2012-12-31	$0
Interest earned on other investments	2012-12-31	$147
Income. Interest from US Government securities	2012-12-31	$0
Income. Interest from corporate debt instruments	2012-12-31	$0
Value of interest in common/collective trusts at end of year	2012-12-31	$432,062
Value of interest in common/collective trusts at beginning of year	2012-12-31	$0
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2012-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$34,745
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$0
Expenses. Payments to insurance carriers foe the provision of benefits	2012-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2012-12-31	$1,257
Net investment gain/loss from pooled separate accounts	2012-12-31	$826
Net investment gain or loss from common/collective trusts	2012-12-31	$10,102
Net gain/loss from 103.12 investment entities	2012-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$0
Employer contributions (assets) at end of year	2012-12-31	$0
Employer contributions (assets) at beginning of year	2012-12-31	$0
Income. Dividends from preferred stock	2012-12-31	$0
Income. Dividends from common stock	2012-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$3,123
Contract administrator fees	2012-12-31	$2,433
Liabilities. Value of benefit claims payable at beginning of year	2012-12-31	$0
Did the plan have assets held for investment	2012-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Aggregate proceeds on sale of assets	2012-12-31	$0
Aggregate carrying amount (costs) on sale of assets	2012-12-31	$0
Liabilities. Value of acquisition indebtedness at beginning of year	2012-12-31	$0

Form 5500 Responses for HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN

2016: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	This submission is the final filing	Yes
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	Yes
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: HOMETOWN URGENT CARE 401(K) RETIREMENT SAVINGS PLAN 2012 form 5500 responses
2012-07-01	Type of plan entity	Single employer plan
2012-07-01	First time form 5500 has been submitted	Yes
2012-07-01	This submission is the final filing	No
2012-07-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2012-07-01	Plan is a collectively bargained plan	No
2012-07-01	Plan funding arrangement – Insurance	Yes
2012-07-01	Plan funding arrangement – Trust	Yes
2012-07-01	Plan benefit arrangement – Insurance	Yes
2012-07-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

613953

Policy instance

Insurance contract or identification number	613953
Number of Individuals Covered	0
Insurance policy start date	2016-01-01
Insurance policy end date	2016-06-21
Total amount of commissions paid to insurance broker	USD $51
Total amount of fees paid to insurance company	USD $11
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $51
Amount paid for insurance broker fees	11
Additional information about fees paid to insurance broker	PRORATED INCENTIVE, NOT DEDUCTED FROM PLAN
Insurance broker organization code?	3
Insurance broker name	LOCKTON FINANCIAL ADVISORS LLC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

618529

Policy instance

Insurance contract or identification number	618529
Number of Individuals Covered	0
Insurance policy start date	2016-01-01
Insurance policy end date	2016-06-21
Total amount of commissions paid to insurance broker	USD $172
Total amount of fees paid to insurance company	USD $40
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $172
Amount paid for insurance broker fees	40
Additional information about fees paid to insurance broker	PRORATED INCENTIVE, NOT DEDUCTED FROM PLAN
Insurance broker organization code?	3
Insurance broker name	LOCKTON FINANCIAL ADVISORS LLC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

613953

Policy instance

Insurance contract or identification number	613953
Number of Individuals Covered	187
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $182
Total amount of fees paid to insurance company	USD $19
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $182
Amount paid for insurance broker fees	19
Additional information about fees paid to insurance broker	PRORATED INCENTIVE, NOT DEDUCTED FROM PLAN
Insurance broker organization code?	3
Insurance broker name	LOCKTON FINANCIAL ADVISORS LLC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

618529

Policy instance

Insurance contract or identification number	618529
Number of Individuals Covered	187
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $454
Total amount of fees paid to insurance company	USD $47
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $454
Amount paid for insurance broker fees	47
Additional information about fees paid to insurance broker	PRORATED INCENTIVE, NOT DEDUCTED FROM PLAN
Insurance broker organization code?	3
Insurance broker name	LOCKTON FINANCIAL ADVISORS LLC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

613953

Policy instance

Insurance contract or identification number	613953
Number of Individuals Covered	202
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $255
Total amount of fees paid to insurance company	USD $14
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $255
Amount paid for insurance broker fees	14
Additional information about fees paid to insurance broker	PRORATED INCENTIVE, NOT DEDUCTED FROM PLAN
Insurance broker organization code?	3
Insurance broker name	LOCKTON FINANCIAL ADVISORS LLC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

618529

Policy instance

Insurance contract or identification number	618529
Number of Individuals Covered	202
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $416
Total amount of fees paid to insurance company	USD $45
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $416
Amount paid for insurance broker fees	45
Additional information about fees paid to insurance broker	PRORATED INCENTIVE, NOT DEDUCTED FROM PLAN
Insurance broker organization code?	3
Insurance broker name	LOCKTON FINANCIAL ADVISORS LLC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

613953

Policy instance

Insurance contract or identification number	613953
Number of Individuals Covered	251
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,729
Total amount of fees paid to insurance company	USD $866
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,729
Amount paid for insurance broker fees	866
Additional information about fees paid to insurance broker	REFERRAL/SERVICE FEE AND PRORATED INCENTIVE, NOT DEDUCTED FROM PLAN
Insurance broker organization code?	3
Insurance broker name	LOCKTON FINANCIAL ADVISORS LLC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

618529

Policy instance

Insurance contract or identification number	618529
Number of Individuals Covered	251
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

618529

Policy instance

Insurance contract or identification number	618529
Number of Individuals Covered	299
Insurance policy start date	2012-07-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

613953

Policy instance

Insurance contract or identification number	613953
Number of Individuals Covered	299
Insurance policy start date	2012-07-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $477
Total amount of fees paid to insurance company	USD $32
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $477
Amount paid for insurance broker fees	32
Additional information about fees paid to insurance broker	REFERRAL/SERVICE FEE
Insurance broker organization code?	3
Insurance broker name	LOCKTON FINANCIAL ADVISORS LLC

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Company Name:	HOMETOWN URGENT CARE
Employer identification number (EIN):	454745431
NAIC Classification:	621610
NAIC Description:	Home Health Care Services