401k Plan data: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN plan

CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN 401k Plan overview

Plan Name	CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN
Plan identification number	502

CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

SOUTH DENVER ANESTHESIOLOGISTS P.C. has sponsored the creation of one or more 401k plans.

Company Name: SOUTH DENVER ANESTHESIOLOGISTS P.C.

Employer identification number (EIN): 840604391

NAIC Classification: 621111
NAIC Description: Offices of Physicians (except Mental Health Specialists)

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2016-01-01 MARTHA WATSON
502 2015-01-01 MARTHA WATSON MARTHA WATSON 2016-09-30

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2016-01-01	MARTHA WATSON
502	2015-01-01	MARTHA WATSON		MARTHA WATSON	2016-09-30

Plan Statistics for CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN

401k plan membership statisitcs for CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN

Measure Date Value
2016: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 101
Number of retired or separated participants receiving benefits 2016-01-01 1
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 102
2015: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 68
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 100
Number of retired or separated participants receiving benefits 2015-01-01 1
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 101

Measure	Date	Value
2016: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	101
Number of retired or separated participants receiving benefits	2016-01-01	1
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	102
2015: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	68
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	100
Number of retired or separated participants receiving benefits	2015-01-01	1
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	101

Form 5500 Responses for CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN

2016: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: CAFETERIA WRAP PLAN DOCUMENT AND SUMMARY PLAN DOCUMENT FOR THE SOUTH DENVER ANESTHESIOLOGISTS PC BENEFIT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	First time form 5500 has been submitted	Yes
2015-01-01	Submission has been amended	No
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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

767349G

Policy instance

Insurance contract or identification number	767349G
Number of Individuals Covered	100
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,256
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $12,562
Commission paid to Insurance Broker	USD $1,256
Insurance broker organization code?	3
Insurance broker name	COBIZ INSURANCE

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

579700

Policy instance

Insurance contract or identification number	579700
Number of Individuals Covered	67
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $41,080
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	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $1,027,018
Commission paid to Insurance Broker	USD $41,080
Insurance broker organization code?	3
Insurance broker name	COBIZ INSURANCE

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Company Name:	SOUTH DENVER ANESTHESIOLOGISTS P.C.
Employer identification number (EIN):	840604391
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)