401k Plan data: SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN plan

SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN 401k Plan overview

Plan Name	SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN
Plan identification number	001

SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT 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.
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.
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

CARL GUSTAFSON, P.C. has sponsored the creation of one or more 401k plans.

Company Name: CARL GUSTAFSON, P.C.

Employer identification number (EIN): 043256572

NAIC Classification: 621340
NAIC Description: Offices of Physical, Occupational and Speech Therapists, and Audiologists

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2016-01-01
001 2015-01-01 CARL GUSTAFSON
001 2014-01-01 CARL GUSTAFSON
001 2013-01-01 CARL GUSTAFSON 2014-10-08
001 2012-01-01 CARL GUSTAFSON 2013-09-27
001 2011-01-01 CARL GUSTAFSON 2012-06-18
001 2010-01-01 CARL GUSTAFSON 2011-09-28

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2016-01-01
001	2015-01-01	CARL GUSTAFSON
001	2014-01-01	CARL GUSTAFSON
001	2013-01-01	CARL GUSTAFSON	2014-10-08
001	2012-01-01	CARL GUSTAFSON	2013-09-27
001	2011-01-01	CARL GUSTAFSON	2012-06-18
001	2010-01-01	CARL GUSTAFSON	2011-09-28

Plan Statistics for SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN

401k plan membership statisitcs for SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN

Measure Date Value
2016: SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 148
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: SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 156
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 0
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 148
Total of all active and inactive participants 2015-01-01 148
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 148
Number of participants with account balances 2015-01-01 148
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 0
2014: SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 133
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 96
Number of retired or separated participants receiving benefits 2014-01-01 45
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 141
Number of participants with account balances 2014-01-01 141
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0

Measure	Date	Value
2016: SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	148
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: SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	156
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	0
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	148
Total of all active and inactive participants	2015-01-01	148
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	148
Number of participants with account balances	2015-01-01	148
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	0
2014: SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	133
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	96
Number of retired or separated participants receiving benefits	2014-01-01	45
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	141
Number of participants with account balances	2014-01-01	141
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0

Financial Data on SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN

Measure	Date	Value
2016 : SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-04-30	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-04-30	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-04-30	$0
Total income from all sources (including contributions)	2016-04-30	$-257,536
Total loss/gain on sale of assets	2016-04-30	$0
Total of all expenses incurred	2016-04-30	$4,879,896
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-04-30	$4,876,577
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-04-30	$2,595
Value of total assets at end of year	2016-04-30	$0
Value of total assets at beginning of year	2016-04-30	$5,137,432
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-04-30	$3,319
Total interest from all sources	2016-04-30	$344
Total dividends received (eg from common stock, registered investment company shares)	2016-04-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-04-30	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2016-04-30	$0
Was this plan covered by a fidelity bond	2016-04-30	Yes
Value of fidelity bond cover	2016-04-30	$500,000
If this is an individual account plan, was there a blackout period	2016-04-30	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-04-30	$0
Were there any nonexempt tranactions with any party-in-interest	2016-04-30	No
Participant contributions at end of year	2016-04-30	$0
Participant contributions at beginning of year	2016-04-30	$55,038
Other income not declared elsewhere	2016-04-30	$3,294
Administrative expenses (other) incurred	2016-04-30	$3,319
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-04-30	No
Value of net income/loss	2016-04-30	$-5,137,432
Value of net assets at end of year (total assets less liabilities)	2016-04-30	$0
Value of net assets at beginning of year (total assets less liabilities)	2016-04-30	$5,137,432
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-04-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-04-30	No
Were any leases to which the plan was party in default or uncollectible	2016-04-30	No
Value of interest in pooled separate accounts at end of year	2016-04-30	$0
Value of interest in pooled separate accounts at beginning of year	2016-04-30	$5,053,421
Interest on participant loans	2016-04-30	$245
Interest earned on other investments	2016-04-30	$99
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2016-04-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2016-04-30	$28,973
Net investment gain/loss from pooled separate accounts	2016-04-30	$-263,769
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-04-30	No
Was there a failure to transmit to the plan any participant contributions	2016-04-30	No
Has the plan failed to provide any benefit when due under the plan	2016-04-30	No
Contributions received in cash from employer	2016-04-30	$2,595
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-04-30	$4,876,577
Did the plan have assets held for investment	2016-04-30	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	2016-04-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-04-30	Yes
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-04-30	Yes
Opinion of an independent qualified public accountant for this plan	2016-04-30	Disclaimer
Accountancy firm name	2016-04-30	SIEGRIST, CREE,ALESSANDRI & STRAUSS
Accountancy firm EIN	2016-04-30	042745810
2015 : SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets	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	$609,658
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$81,439
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$66,494
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$640,569
Value of total assets at end of year	2015-12-31	$5,137,432
Value of total assets at beginning of year	2015-12-31	$4,609,213
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$14,945
Total interest from all sources	2015-12-31	$1,881
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2015-12-31	$0
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$500,000
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
Contributions received from participants	2015-12-31	$395,121
Participant contributions at end of year	2015-12-31	$55,038
Participant contributions at beginning of year	2015-12-31	$40,868
Income. Received or receivable in cash from other sources (including rollovers)	2015-12-31	$41,725
Other income not declared elsewhere	2015-12-31	$14,533
Administrative expenses (other) incurred	2015-12-31	$14,945
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	$528,219
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$5,137,432
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$4,609,213
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
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest in pooled separate accounts at end of year	2015-12-31	$5,053,421
Value of interest in pooled separate accounts at beginning of year	2015-12-31	$4,543,838
Interest on participant loans	2015-12-31	$1,561
Interest earned on other investments	2015-12-31	$320
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-12-31	$28,973
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$24,507
Net investment gain/loss from pooled separate accounts	2015-12-31	$-47,325
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	$203,723
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$66,494
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
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	SIEGRIST, CREE,ALESSANDRI & STRAUSS
Accountancy firm EIN	2015-12-31	042745810
2014 : SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets	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	$819,972
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$236,663
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$218,914
Expenses. Certain deemed distributions of participant loans	2014-12-31	$4,105
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$541,088
Value of total assets at end of year	2014-12-31	$4,609,213
Value of total assets at beginning of year	2014-12-31	$4,025,904
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$13,644
Total interest from all sources	2014-12-31	$1,494
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$403,000
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
Contributions received from participants	2014-12-31	$342,245
Participant contributions at end of year	2014-12-31	$40,868
Participant contributions at beginning of year	2014-12-31	$25,669
Income. Received or receivable in cash from other sources (including rollovers)	2014-12-31	$5,928
Other income not declared elsewhere	2014-12-31	$13,281
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	$583,309
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$4,609,213
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$4,025,904
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
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest in pooled separate accounts at end of year	2014-12-31	$4,543,838
Value of interest in pooled separate accounts at beginning of year	2014-12-31	$3,979,605
Interest on participant loans	2014-12-31	$1,212
Interest earned on other investments	2014-12-31	$282
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$24,507
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$20,630
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$264,109
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	$192,915
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$218,914
Contract administrator fees	2014-12-31	$13,644
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
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	SIEGRIST, CREE,ALESSANDRI & STRAUSS
Accountancy firm EIN	2014-12-31	042745810

Form 5500 Responses for SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN

2016: SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT 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	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: SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
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 funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: SPORTS & PHYSICAL THERAPY ASSOCIATES RETIREMENT 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 – 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

Insurance Providers Used on plan

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

941220-01

Policy instance

Insurance contract or identification number	941220-01
Number of Individuals Covered	0
Insurance policy start date	2016-01-01
Insurance policy end date	2016-04-30
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?	Yes
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

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

941220-01

Policy instance

Insurance contract or identification number	941220-01
Number of Individuals Covered	148
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
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?	Yes
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

GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68322 )

Policy contract number

941220-01

Policy instance

Insurance contract or identification number	941220-01
Number of Individuals Covered	141
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,333
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?	Yes
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 $1,333
Insurance broker organization code?	3
Insurance broker name	LPL FINANCIAL LLC

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Company Name:	CARL GUSTAFSON, P.C.
Employer identification number (EIN):	043256572
NAIC Classification:	621340
NAIC Description:	Offices of Physical, Occupational and Speech Therapists, and Audiologists