401k Plan data: CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN plan

CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 401k Plan overview

Plan Name	CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN
Plan identification number	001

CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING 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.
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

CLS HEALTH PLLC has sponsored the creation of one or more 401k plans.

Company Name: CLS HEALTH PLLC

Employer identification number (EIN): 202798379

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2022-01-01
001 2021-01-01
001 2020-01-01
001 2018-01-01 M.J. BABA, M.D. 2019-06-07
001 2017-01-01 M.J. BABA, M.D. 2018-10-10
001 2016-01-01
001 2015-01-01
001 2015-01-01
001 2014-01-01 M. J. BABA, M.D. 2015-10-08
001 2013-01-01 M. J. BABA, M.D. 2014-08-29
001 2012-01-01 M. J. BABA, M.D. 2013-10-04
001 2011-01-01 M. J. BABA, M.D. 2012-10-12
001 2010-01-01 M. J. BABA, M.D. 2011-10-10

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2022-01-01
001	2021-01-01
001	2020-01-01
001	2018-01-01	M.J. BABA, M.D.	2019-06-07
001	2017-01-01	M.J. BABA, M.D.	2018-10-10
001	2016-01-01
001	2015-01-01
001	2015-01-01
001	2014-01-01	M. J. BABA, M.D.	2015-10-08
001	2013-01-01	M. J. BABA, M.D.	2014-08-29
001	2012-01-01	M. J. BABA, M.D.	2013-10-04
001	2011-01-01	M. J. BABA, M.D.	2012-10-12
001	2010-01-01	M. J. BABA, M.D.	2011-10-10

Plan Statistics for CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN

401k plan membership statisitcs for CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN

Measure Date Value
2022: CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 174
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 130
Number of retired or separated participants receiving benefits 2022-01-01 4
Number of other retired or separated participants entitled to future benefits 2022-01-01 28
Total of all active and inactive participants 2022-01-01 162
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 162
Number of participants with account balances 2022-01-01 88
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 1
2021: CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 176
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 122
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 37
Total of all active and inactive participants 2021-01-01 159
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 159
Number of participants with account balances 2021-01-01 83
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 0
2020: CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 128
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 14
Total of all active and inactive participants 2020-01-01 142
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 142
Number of participants with account balances 2020-01-01 85
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0

Measure	Date	Value
2022: CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	174
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	130
Number of retired or separated participants receiving benefits	2022-01-01	4
Number of other retired or separated participants entitled to future benefits	2022-01-01	28
Total of all active and inactive participants	2022-01-01	162
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	162
Number of participants with account balances	2022-01-01	88
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	1
2021: CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	176
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	122
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	37
Total of all active and inactive participants	2021-01-01	159
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	159
Number of participants with account balances	2021-01-01	83
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	0
2020: CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	128
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	14
Total of all active and inactive participants	2020-01-01	142
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	142
Number of participants with account balances	2020-01-01	85
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0

Financial Data on CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN

Measure	Date	Value
2022 : CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2022 401k financial data
Total income from all sources (including contributions)	2022-12-31	$-611,364
Total of all expenses incurred	2022-12-31	$633,523
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$628,941
Expenses. Certain deemed distributions of participant loans	2022-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$810,042
Value of total assets at end of year	2022-12-31	$5,991,806
Value of total assets at beginning of year	2022-12-31	$7,236,693
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$4,582
Total interest from all sources	2022-12-31	$1,507
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2022-12-31	$0
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$600,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$533,330
Participant contributions at end of year	2022-12-31	$16,107
Participant contributions at beginning of year	2022-12-31	$93,942
Participant contributions at end of year	2022-12-31	$0
Participant contributions at beginning of year	2022-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2022-12-31	$4
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2022-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at beginning of year	2022-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-1,244,887
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$5,991,806
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$7,236,693
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$4,038,852
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$5,043,451
Interest on participant loans	2022-12-31	$1,507
Value of interest in common/collective trusts at end of year	2022-12-31	$1,808,735
Value of interest in common/collective trusts at beginning of year	2022-12-31	$1,940,037
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2022-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$63,813
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$64,912
Expenses. Payments to insurance carriers foe the provision of benefits	2022-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-1,422,913
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$276,712
Employer contributions (assets) at end of year	2022-12-31	$64,295
Employer contributions (assets) at beginning of year	2022-12-31	$94,351
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$628,941
Contract administrator fees	2022-12-31	$4,582
Did the plan have assets held for investment	2022-12-31	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	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	HAYNIE & COMPANY
Accountancy firm EIN	2022-12-31	870325228
2021 : CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2021 401k financial data
Total income from all sources (including contributions)	2021-12-31	$2,315,218
Total of all expenses incurred	2021-12-31	$179,082
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$176,844
Expenses. Certain deemed distributions of participant loans	2021-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$1,281,204
Value of total assets at end of year	2021-12-31	$7,236,693
Value of total assets at beginning of year	2021-12-31	$5,100,557
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$2,238
Total interest from all sources	2021-12-31	$5,566
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2021-12-31	$0
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$600,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$876,788
Participant contributions at end of year	2021-12-31	$93,942
Participant contributions at beginning of year	2021-12-31	$111,292
Participant contributions at end of year	2021-12-31	$0
Participant contributions at beginning of year	2021-12-31	$31,134
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$0
Value of other receiveables (less allowance for doubtful accounts) at end of year	2021-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$2,136,136
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$7,236,693
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$5,100,557
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$5,043,451
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$2,957,848
Interest on participant loans	2021-12-31	$5,566
Value of interest in common/collective trusts at end of year	2021-12-31	$1,940,037
Value of interest in common/collective trusts at beginning of year	2021-12-31	$1,824,164
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2021-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$64,912
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$154,576
Expenses. Payments to insurance carriers foe the provision of benefits	2021-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$1,028,448
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$404,416
Employer contributions (assets) at end of year	2021-12-31	$94,351
Employer contributions (assets) at beginning of year	2021-12-31	$21,543
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$176,844
Contract administrator fees	2021-12-31	$2,238
Did the plan have assets held for investment	2021-12-31	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	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	HAYNIE & COMPANY
Accountancy firm EIN	2021-12-31	870325228
2020 : CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2020 401k financial data
Total income from all sources (including contributions)	2020-12-31	$1,766,314
Total of all expenses incurred	2020-12-31	$389,431
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$387,860
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$1,158,877
Value of total assets at end of year	2020-12-31	$5,100,557
Value of total assets at beginning of year	2020-12-31	$3,723,674
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$1,571
Total interest from all sources	2020-12-31	$2,549
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$600,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2020-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$728,175
Participant contributions at end of year	2020-12-31	$111,292
Participant contributions at beginning of year	2020-12-31	$0
Participant contributions at end of year	2020-12-31	$31,134
Participant contributions at beginning of year	2020-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$8,272
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$1,376,883
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$5,100,557
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$3,723,674
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$2,957,848
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$2,201,775
Interest on participant loans	2020-12-31	$2,493
Interest earned on other investments	2020-12-31	$56
Value of interest in common/collective trusts at end of year	2020-12-31	$1,824,164
Value of interest in common/collective trusts at beginning of year	2020-12-31	$1,409,750
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$154,576
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-12-31	$112,149
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$604,888
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$422,430
Employer contributions (assets) at end of year	2020-12-31	$21,543
Employer contributions (assets) at beginning of year	2020-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$387,860
Contract administrator fees	2020-12-31	$1,571
Did the plan have assets held for investment	2020-12-31	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	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Disclaimer
Accountancy firm name	2020-12-31	HAYNIE & COMPANY
Accountancy firm EIN	2020-12-31	870325228

Form 5500 Responses for CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN

2022: CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: CLEAR LAKE SPECIALTIES, P.A. 401(K) PROFIT SHARING PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

GA841776

Policy instance

Insurance contract or identification number	GA841776
Number of Individuals Covered	0
Insurance policy start date	2022-01-01
Insurance policy end date	2022-06-30
Total amount of commissions paid to insurance broker	USD $24,987
Total amount of fees paid to insurance company	USD $1,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $24,987
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	BROKER COMMISSIONS
Insurance broker organization code?	3

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

758550-01

Policy instance

Insurance contract or identification number	758550-01
Number of Individuals Covered	88
Insurance policy start date	2022-06-18
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $23,246
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
Commission paid to Insurance Broker	USD $23,246
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	BROKER COMMISSIONS
Insurance broker organization code?	3

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

GA841776

Policy instance

Insurance contract or identification number	GA841776
Number of Individuals Covered	88
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $41,140
Total amount of fees paid to insurance company	USD $2,743
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $41,140
Additional information about fees paid to insurance broker	BROKER COMMISSION
Insurance broker organization code?	3
Amount paid for insurance broker fees	2743

MASSACHUSETTS MUTUAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65935 )

Policy contract number

GA841776

Policy instance

Insurance contract or identification number	GA841776
Number of Individuals Covered	84
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $27,427
Total amount of fees paid to insurance company	USD $1,825
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,427
Insurance broker organization code?	3
Amount paid for insurance broker fees	1825
Additional information about fees paid to insurance broker	ADMINISTRATIVE ALLOWANCE

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Company Name:	CLS HEALTH PLLC
Employer identification number (EIN):	202798379
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)