401k Plan data: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN plan

CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 401k Plan overview

Plan Name	CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN
Plan identification number	003

CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
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.
Participant-directed brokerage accounts provided as an investment option under the plan.
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.
Life insurance

401k Sponsoring company profile

CHAG ANESTHESIA, P.C. has sponsored the creation of one or more 401k plans.

Company Name: CHAG ANESTHESIA, P.C.

Employer identification number (EIN): 161075185

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

Additional information about CHAG ANESTHESIA, P.C.

Jurisdiction of Incorporation: New York Department of State

Incorporation Date: 1976-11-18

Company Identification Number: 415447

Legal Registered Office Address: 5000 BRITTONFIELD PARKWAY
Onondaga
EAST SYRACUSE
United States of America (USA)
13057

More information about CHAG ANESTHESIA, P.C.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
003 2022-01-01 JEFFREY S SCHAFFEL 2023-06-01 JEFFREY S SCHAFFEL 2023-06-01
003 2021-01-01 JEFFREY SCHAFFELL 2022-06-05 JEFFREY SCHAFFELL 2022-06-05
003 2020-01-01 JEFFREY SCHAFFEL 2021-06-09 JEFFREY SCHAFFEL 2021-06-09
003 2019-01-01 JEFFREY SCHAFFEL 2020-09-06 JEFFREY SCHAFFEL 2020-09-06
003 2018-01-01 JEFFREY SCHAFFEL 2019-08-30 JEFFREY SCHAFFEL 2019-08-30
003 2017-01-01 JEFFREY SCHAFFEL 2018-09-15 JEFFREY SCHAFFEL 2018-09-15
003 2016-01-01 BARTHOLEMEW NATOLI 2017-09-17 BARTHOLEMEW NATOLI 2017-09-17
003 2015-01-01 BARTHOLEMEW NATOLI 2016-09-16 BARTHOLEMEW NATOLI 2016-09-16
003 2014-01-01 BARTHOLEMEW NATOLI MD BARTHOLEMEW NATOLI MD 2015-09-10
003 2013-01-01 BARTHOLEMEW NATOLI BARTHOLEMEW NATOLI 2014-09-17
003 2012-01-01 BARTHOLEMEW NATOLI BARTHOLEMEW NATOLI 2013-09-23
003 2011-01-01 BARTHOLEMEW NATOLI BARTHOLEMEW NATOLI 2012-10-02
003 2010-01-01 BARTHOLEMEW NATOLI 2011-09-15 BARTHOLEMEW NATOLI 2011-09-15

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
003	2022-01-01	JEFFREY S SCHAFFEL	2023-06-01	JEFFREY S SCHAFFEL	2023-06-01
003	2021-01-01	JEFFREY SCHAFFELL	2022-06-05	JEFFREY SCHAFFELL	2022-06-05
003	2020-01-01	JEFFREY SCHAFFEL	2021-06-09	JEFFREY SCHAFFEL	2021-06-09
003	2019-01-01	JEFFREY SCHAFFEL	2020-09-06	JEFFREY SCHAFFEL	2020-09-06
003	2018-01-01	JEFFREY SCHAFFEL	2019-08-30	JEFFREY SCHAFFEL	2019-08-30
003	2017-01-01	JEFFREY SCHAFFEL	2018-09-15	JEFFREY SCHAFFEL	2018-09-15
003	2016-01-01	BARTHOLEMEW NATOLI	2017-09-17	BARTHOLEMEW NATOLI	2017-09-17
003	2015-01-01	BARTHOLEMEW NATOLI	2016-09-16	BARTHOLEMEW NATOLI	2016-09-16
003	2014-01-01	BARTHOLEMEW NATOLI MD		BARTHOLEMEW NATOLI MD	2015-09-10
003	2013-01-01	BARTHOLEMEW NATOLI		BARTHOLEMEW NATOLI	2014-09-17
003	2012-01-01	BARTHOLEMEW NATOLI		BARTHOLEMEW NATOLI	2013-09-23
003	2011-01-01	BARTHOLEMEW NATOLI		BARTHOLEMEW NATOLI	2012-10-02
003	2010-01-01	BARTHOLEMEW NATOLI	2011-09-15	BARTHOLEMEW NATOLI	2011-09-15

Plan Statistics for CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN

401k plan membership statisitcs for CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN

Measure Date Value
2014: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 35
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 32
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 3
Total of all active and inactive participants 2014-01-01 35
Total participants 2014-01-01 35
Number of participants with account balances 2014-01-01 35
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 1
2013: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 35
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 30
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 2
Total of all active and inactive participants 2013-01-01 32
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 32
Number of participants with account balances 2013-01-01 32
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 2
2012: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 34
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 30
Number of other retired or separated participants entitled to future benefits 2012-01-01 4
Total of all active and inactive participants 2012-01-01 34
Total participants 2012-01-01 34
Number of participants with account balances 2012-01-01 34
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 1
2011: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 30
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 29
Number of other retired or separated participants entitled to future benefits 2011-01-01 2
Total of all active and inactive participants 2011-01-01 31
Total participants 2011-01-01 31
Number of participants with account balances 2011-01-01 31
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 1

Measure	Date	Value
2014: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	35
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	32
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	3
Total of all active and inactive participants	2014-01-01	35
Total participants	2014-01-01	35
Number of participants with account balances	2014-01-01	35
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	1
2013: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	35
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	30
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	2
Total of all active and inactive participants	2013-01-01	32
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	32
Number of participants with account balances	2013-01-01	32
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	2
2012: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	34
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	30
Number of other retired or separated participants entitled to future benefits	2012-01-01	4
Total of all active and inactive participants	2012-01-01	34
Total participants	2012-01-01	34
Number of participants with account balances	2012-01-01	34
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	1
2011: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	30
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	29
Number of other retired or separated participants entitled to future benefits	2011-01-01	2
Total of all active and inactive participants	2011-01-01	31
Total participants	2011-01-01	31
Number of participants with account balances	2011-01-01	31
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	1

Financial Data on CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN

Measure	Date	Value
2014 : CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2014 401k financial data
Total plan liabilities at end of year	2014-12-31	$2,306
Total plan liabilities at beginning of year	2014-12-31	$510
Total income from all sources	2014-12-31	$1,988,087
Expenses. Total of all expenses incurred	2014-12-31	$653,384
Benefits paid (including direct rollovers)	2014-12-31	$592,141
Total plan assets at end of year	2014-12-31	$14,218,911
Total plan assets at beginning of year	2014-12-31	$12,882,412
Value of fidelity bond covering the plan	2014-12-31	$500,000
Total contributions received or receivable from participants	2014-12-31	$527,221
Expenses. Other expenses not covered elsewhere	2014-12-31	$61,243
Other income received	2014-12-31	$787,580
Net income (gross income less expenses)	2014-12-31	$1,334,703
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$14,216,605
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$12,881,902
Assets. Value of participant loans	2014-12-31	$121,855
Assets. Value of assets in partnership/joint-venture interests	2014-12-31	$291,428
Total contributions received or receivable from employer(s)	2014-12-31	$673,286
2013 : CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2013 401k financial data
Total plan liabilities at end of year	2013-12-31	$510
Total plan liabilities at beginning of year	2013-12-31	$424
Total income from all sources	2013-12-31	$2,805,034
Expenses. Total of all expenses incurred	2013-12-31	$342,598
Benefits paid (including direct rollovers)	2013-12-31	$289,061
Total plan assets at end of year	2013-12-31	$12,882,412
Total plan assets at beginning of year	2013-12-31	$10,419,890
Value of fidelity bond covering the plan	2013-12-31	$500,000
Total contributions received or receivable from participants	2013-12-31	$516,990
Expenses. Other expenses not covered elsewhere	2013-12-31	$53,537
Other income received	2013-12-31	$1,612,382
Net income (gross income less expenses)	2013-12-31	$2,462,436
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$12,881,902
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$10,419,466
Assets. Value of participant loans	2013-12-31	$120,337
Assets. Value of assets in partnership/joint-venture interests	2013-12-31	$322,666
Total contributions received or receivable from employer(s)	2013-12-31	$675,662
2012 : CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2012 401k financial data
Total plan liabilities at end of year	2012-12-31	$424
Total income from all sources	2012-12-31	$1,980,827
Expenses. Total of all expenses incurred	2012-12-31	$114,303
Benefits paid (including direct rollovers)	2012-12-31	$66,405
Total plan assets at end of year	2012-12-31	$10,419,890
Total plan assets at beginning of year	2012-12-31	$8,552,942
Value of fidelity bond covering the plan	2012-12-31	$500,000
Total contributions received or receivable from participants	2012-12-31	$514,679
Expenses. Other expenses not covered elsewhere	2012-12-31	$47,898
Other income received	2012-12-31	$765,651
Net income (gross income less expenses)	2012-12-31	$1,866,524
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$10,419,466
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$8,552,942
Assets. Value of participant loans	2012-12-31	$89,693
Assets. Value of assets in partnership/joint-venture interests	2012-12-31	$309,913
Total contributions received or receivable from employer(s)	2012-12-31	$700,497
2011 : CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN 2011 401k financial data
Total income from all sources	2011-12-31	$918,321
Expenses. Total of all expenses incurred	2011-12-31	$628,143
Benefits paid (including direct rollovers)	2011-12-31	$590,357
Total plan assets at end of year	2011-12-31	$8,552,942
Total plan assets at beginning of year	2011-12-31	$8,262,764
Value of fidelity bond covering the plan	2011-12-31	$500,000
Total contributions received or receivable from participants	2011-12-31	$472,454
Expenses. Other expenses not covered elsewhere	2011-12-31	$37,786
Other income received	2011-12-31	$-190,190
Net income (gross income less expenses)	2011-12-31	$290,178
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$8,552,942
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$8,262,764
Assets. Value of participant loans	2011-12-31	$120,805
Assets. Value of assets in partnership/joint-venture interests	2011-12-31	$251,175
Total contributions received or receivable from employer(s)	2011-12-31	$636,057

Form 5500 Responses for CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING PLAN

2014: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING 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
2013: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING 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 – 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: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING 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 – Insurance	Yes
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: CHAG ANESTHESIA, PC EMPLOYEES DEFERRED SAVINGS AND PROFIT SHARING 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 – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

PENN MUTUAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 67644 )

Policy contract number

8558T

Policy instance

Insurance contract or identification number	8558T
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 $115
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $57
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GLENN HAMEISTER

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

37923

Policy instance

Insurance contract or identification number	37923
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 $233
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $0
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	233
Additional information about fees paid to insurance broker	PERSISTENCY FEES, OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JOHN G KINNEY

PENN MUTUAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 67644 )

Policy contract number

8558T

Policy instance

Insurance contract or identification number	8558T
Number of Individuals Covered	1
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $115
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $57
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GLENN HAMEISTER

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

37923

Policy instance

Insurance contract or identification number	37923
Number of Individuals Covered	1
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 $233
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,318
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	233
Additional information about fees paid to insurance broker	PERSISTENCY FEES, OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JOHN G KINNEY

MONY LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 66370 )

Policy contract number

950300

Policy instance

Insurance contract or identification number	950300
Number of Individuals Covered	0
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PENN MUTUAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 67644 )

Policy contract number

8558T

Policy instance

Insurance contract or identification number	8558T
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $229
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,360
Commission paid to Insurance Broker	USD $114
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	GLENN HAMEISTER

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

37923

Policy instance

Insurance contract or identification number	37923
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
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 $233
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $5,043
Commission paid to Insurance Broker	USD $0
Amount paid for insurance broker fees	233
Additional information about fees paid to insurance broker	PERSISTENCY FEES, OTHER COMPENSATION
Insurance broker organization code?	3
Insurance broker name	JOHN G KINNEY

MONY LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 66370 )

Policy contract number

950300

Policy instance

Insurance contract or identification number	950300
Number of Individuals Covered	1
Insurance policy start date	2012-01-01
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
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes

PENN MUTUAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 67644 )

Policy contract number

8558T

Policy instance

Insurance contract or identification number	8558T
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $2,635
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

MONY LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 66370 )

Policy contract number

950300

Policy instance

Insurance contract or identification number	950300
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 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

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

37923

Policy instance

Insurance contract or identification number	37923
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
Life Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $4,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	CHAG ANESTHESIA, P.C.
Employer identification number (EIN):	161075185
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)

Jurisdiction of Incorporation:	New York Department of State
Incorporation Date:	1976-11-18
Company Identification Number:	415447
Legal Registered Office Address:	5000 BRITTONFIELD PARKWAY Onondaga EAST SYRACUSE United States of America (USA) 13057