401k Plan data: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN plan

DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 401k Plan overview

Plan Name	DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN
Plan identification number	001

DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
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.
Participant-directed brokerage accounts provided as an investment option under the plan.
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

DIABLO VALLEY EYE MEDICAL CENTER has sponsored the creation of one or more 401k plans.

Company Name: DIABLO VALLEY EYE MEDICAL CENTER

Employer identification number (EIN): 680345294

NAIC Classification: 621320
NAIC Description: Offices of Optometrists

Form 5500 Filing Information

Submission information for form 5500 for 401k plan DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2021-01-01 DAVID GILBERT 2022-10-07
001 2020-01-01 DAVID GILBERT 2021-08-26
001 2019-01-01 DAVID GILBERT 2020-10-09
001 2018-01-01 DAVID GILBERT 2019-09-26
001 2017-01-01 DAVID GILBERT 2018-07-27
001 2016-01-01 DAVID GILBERT 2017-10-09
001 2015-01-01 JAMES DOWLING, M.D. 2016-10-12
001 2014-01-01 JAMES DOWLING, M.D.
001 2013-01-01 JAMES DOWLING, M.D.
001 2012-01-01 JAMES DOWLING, M.D.
001 2011-01-01 JAMES DOWLING, M.D.
001 2010-01-01 JAMES DOWLING, M.D.
001 2009-01-01 JAMES DOWLING, M.D.

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2021-01-01	DAVID GILBERT	2022-10-07
001	2020-01-01	DAVID GILBERT	2021-08-26
001	2019-01-01	DAVID GILBERT	2020-10-09
001	2018-01-01	DAVID GILBERT	2019-09-26
001	2017-01-01	DAVID GILBERT	2018-07-27
001	2016-01-01	DAVID GILBERT	2017-10-09
001	2015-01-01	JAMES DOWLING, M.D.	2016-10-12
001	2014-01-01	JAMES DOWLING, M.D.
001	2013-01-01	JAMES DOWLING, M.D.
001	2012-01-01	JAMES DOWLING, M.D.
001	2011-01-01	JAMES DOWLING, M.D.
001	2010-01-01	JAMES DOWLING, M.D.
001	2009-01-01	JAMES DOWLING, M.D.

Plan Statistics for DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN

401k plan membership statisitcs for DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN

Measure Date Value
2014: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 25
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 18
Number of retired or separated participants receiving benefits 2014-01-01 2
Number of other retired or separated participants entitled to future benefits 2014-01-01 2
Total of all active and inactive participants 2014-01-01 22
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 22
Number of participants with account balances 2014-01-01 22
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 25
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 20
Number of retired or separated participants receiving benefits 2013-01-01 1
Number of other retired or separated participants entitled to future benefits 2013-01-01 4
Total of all active and inactive participants 2013-01-01 25
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 25
Number of participants with account balances 2013-01-01 25
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 1
2012: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 24
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 20
Number of retired or separated participants receiving benefits 2012-01-01 2
Number of other retired or separated participants entitled to future benefits 2012-01-01 3
Total of all active and inactive participants 2012-01-01 25
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 25
Number of participants with account balances 2012-01-01 25
2011: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 24
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 19
Number of retired or separated participants receiving benefits 2011-01-01 2
Number of other retired or separated participants entitled to future benefits 2011-01-01 3
Total of all active and inactive participants 2011-01-01 24
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 24
Number of participants with account balances 2011-01-01 24
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2010: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 24
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 21
Number of retired or separated participants receiving benefits 2010-01-01 2
Number of other retired or separated participants entitled to future benefits 2010-01-01 1
Total of all active and inactive participants 2010-01-01 24
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 24
Number of participants with account balances 2010-01-01 24
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 24
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 22
Number of retired or separated participants receiving benefits 2009-01-01 1
Number of other retired or separated participants entitled to future benefits 2009-01-01 1
Total of all active and inactive participants 2009-01-01 24
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 24
Number of participants with account balances 2009-01-01 24
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 1

Measure	Date	Value
2014: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	25
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	18
Number of retired or separated participants receiving benefits	2014-01-01	2
Number of other retired or separated participants entitled to future benefits	2014-01-01	2
Total of all active and inactive participants	2014-01-01	22
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	22
Number of participants with account balances	2014-01-01	22
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	25
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	20
Number of retired or separated participants receiving benefits	2013-01-01	1
Number of other retired or separated participants entitled to future benefits	2013-01-01	4
Total of all active and inactive participants	2013-01-01	25
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	25
Number of participants with account balances	2013-01-01	25
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	1
2012: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	24
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	20
Number of retired or separated participants receiving benefits	2012-01-01	2
Number of other retired or separated participants entitled to future benefits	2012-01-01	3
Total of all active and inactive participants	2012-01-01	25
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	25
Number of participants with account balances	2012-01-01	25
2011: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	24
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	19
Number of retired or separated participants receiving benefits	2011-01-01	2
Number of other retired or separated participants entitled to future benefits	2011-01-01	3
Total of all active and inactive participants	2011-01-01	24
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	24
Number of participants with account balances	2011-01-01	24
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2010: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	24
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	21
Number of retired or separated participants receiving benefits	2010-01-01	2
Number of other retired or separated participants entitled to future benefits	2010-01-01	1
Total of all active and inactive participants	2010-01-01	24
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	24
Number of participants with account balances	2010-01-01	24
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	24
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	22
Number of retired or separated participants receiving benefits	2009-01-01	1
Number of other retired or separated participants entitled to future benefits	2009-01-01	1
Total of all active and inactive participants	2009-01-01	24
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	24
Number of participants with account balances	2009-01-01	24
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	1

Financial Data on DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN

Measure	Date	Value
2014 : DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2014 401k financial data
Transfers to/from the plan	2014-12-31	$0
Total plan liabilities at end of year	2014-12-31	$0
Total plan liabilities at beginning of year	2014-12-31	$0
Total income from all sources	2014-12-31	$262,162
Expenses. Total of all expenses incurred	2014-12-31	$542,727
Benefits paid (including direct rollovers)	2014-12-31	$500,657
Total plan assets at end of year	2014-12-31	$4,350,101
Total plan assets at beginning of year	2014-12-31	$4,630,666
Value of fidelity bond covering the plan	2014-12-31	$500,000
Total contributions received or receivable from participants	2014-12-31	$119,246
Expenses. Other expenses not covered elsewhere	2014-12-31	$0
Contributions received from other sources (not participants or employers)	2014-12-31	$0
Other income received	2014-12-31	$86,605
Noncash contributions received	2014-12-31	$0
Net income (gross income less expenses)	2014-12-31	$-280,565
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$4,350,101
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$4,630,666
Assets. Value of participant loans	2014-12-31	$10,439
Total contributions received or receivable from employer(s)	2014-12-31	$56,311
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2014-12-31	$42,070
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
2013 : DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2013 401k financial data
Transfers to/from the plan	2013-12-31	$0
Total plan liabilities at end of year	2013-12-31	$0
Total plan liabilities at beginning of year	2013-12-31	$0
Total income from all sources	2013-12-31	$1,040,869
Expenses. Total of all expenses incurred	2013-12-31	$3,856,578
Benefits paid (including direct rollovers)	2013-12-31	$3,811,331
Total plan assets at end of year	2013-12-31	$4,630,666
Total plan assets at beginning of year	2013-12-31	$7,446,375
Value of fidelity bond covering the plan	2013-12-31	$500,000
Total contributions received or receivable from participants	2013-12-31	$53,833
Expenses. Other expenses not covered elsewhere	2013-12-31	$0
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$882,309
Noncash contributions received	2013-12-31	$0
Net income (gross income less expenses)	2013-12-31	$-2,815,709
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$4,630,666
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$7,446,375
Assets. Value of participant loans	2013-12-31	$36,567
Total contributions received or receivable from employer(s)	2013-12-31	$104,727
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2013-12-31	$45,247
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
2012 : DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2012 401k financial data
Transfers to/from the plan	2012-12-31	$0
Total plan liabilities at end of year	2012-12-31	$0
Total plan liabilities at beginning of year	2012-12-31	$0
Total income from all sources	2012-12-31	$954,156
Expenses. Total of all expenses incurred	2012-12-31	$65,829
Benefits paid (including direct rollovers)	2012-12-31	$22,242
Total plan assets at end of year	2012-12-31	$7,446,375
Total plan assets at beginning of year	2012-12-31	$6,558,048
Value of fidelity bond covering the plan	2012-12-31	$500,000
Total contributions received or receivable from participants	2012-12-31	$112,877
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$785,748
Noncash contributions received	2012-12-31	$0
Net income (gross income less expenses)	2012-12-31	$888,327
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$7,446,375
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$6,558,048
Assets. Value of participant loans	2012-12-31	$35,482
Total contributions received or receivable from employer(s)	2012-12-31	$55,531
Value of certain deemed distributions of participant loans	2012-12-31	$43,587
Value of corrective distributions	2012-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2012-12-31	$0
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
2011 : DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2011 401k financial data
Transfers to/from the plan	2011-12-31	$0
Total plan liabilities at end of year	2011-12-31	$0
Total plan liabilities at beginning of year	2011-12-31	$0
Total income from all sources	2011-12-31	$-116,329
Expenses. Total of all expenses incurred	2011-12-31	$173,815
Benefits paid (including direct rollovers)	2011-12-31	$135,937
Total plan assets at end of year	2011-12-31	$6,558,048
Total plan assets at beginning of year	2011-12-31	$6,848,192
Value of fidelity bond covering the plan	2011-12-31	$500,000
Total contributions received or receivable from participants	2011-12-31	$142,076
Expenses. Other expenses not covered elsewhere	2011-12-31	$15
Contributions received from other sources (not participants or employers)	2011-12-31	$0
Other income received	2011-12-31	$-313,511
Noncash contributions received	2011-12-31	$0
Net income (gross income less expenses)	2011-12-31	$-290,144
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$6,558,048
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$6,848,192
Assets. Value of participant loans	2011-12-31	$44,602
Total contributions received or receivable from employer(s)	2011-12-31	$55,106
Value of certain deemed distributions of participant loans	2011-12-31	$0
Value of corrective distributions	2011-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2011-12-31	$37,863
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
2010 : DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2010 401k financial data
Transfers to/from the plan	2010-12-31	$0
Total plan liabilities at end of year	2010-12-31	$0
Total plan liabilities at beginning of year	2010-12-31	$0
Total income from all sources	2010-12-31	$975,299
Expenses. Total of all expenses incurred	2010-12-31	$42,938
Benefits paid (including direct rollovers)	2010-12-31	$1,101
Total plan assets at end of year	2010-12-31	$6,848,192
Total plan assets at beginning of year	2010-12-31	$5,915,831
Value of fidelity bond covering the plan	2010-12-31	$500,000
Total contributions received or receivable from participants	2010-12-31	$137,007
Expenses. Other expenses not covered elsewhere	2010-12-31	$0
Contributions received from other sources (not participants or employers)	2010-12-31	$0
Other income received	2010-12-31	$771,835
Noncash contributions received	2010-12-31	$0
Net income (gross income less expenses)	2010-12-31	$932,361
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$6,848,192
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$5,915,831
Assets. Value of participant loans	2010-12-31	$59,571
Total contributions received or receivable from employer(s)	2010-12-31	$66,457
Value of certain deemed distributions of participant loans	2010-12-31	$0
Value of corrective distributions	2010-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2010-12-31	$41,837
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
2009 : DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN

2014: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
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 – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
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 – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: DIABLO VALLEY EYE MEDICAL CENTER PROFIT SHARING 401(K) PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

PAN AMERICAN ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 93459 )

Policy contract number

9200525640

Policy instance

Insurance contract or identification number	9200525640
Number of Individuals Covered	1
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	No
Dental Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSION
Insurance broker organization code?	3
Insurance broker name	FLEMING ASSOCIATES INSURANCE AGENCY

PAN AMERICAN ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 93459 )

Policy contract number

9200525640

Policy instance

Insurance contract or identification number	9200525640
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	No
Dental Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PAN AMERICAN ASSURANCE CO. (National Association of Insurance Commissioners NAIC id number: 93459 )

Policy contract number

9200525640

Policy instance

Insurance contract or identification number	9200525640
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	No
Dental Insurance Welfare Benefit	No
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSION
Insurance broker organization code?	3
Insurance broker name	FLEMING ASSOCIATES INSURANCE AGENCY

Potentially related plans

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Company Name:	DIABLO VALLEY EYE MEDICAL CENTER
Employer identification number (EIN):	680345294
NAIC Classification:	621320
NAIC Description:	Offices of Optometrists