401k Plan data: CAPITAL ORTHOPAEDIC CLINIC WELFARE BENEFITS PLAN plan

CAPITAL ORTHOPAEDIC CLINIC WELFARE BENEFITS PLAN 401k Plan overview

Plan Name	CAPITAL ORTHOPAEDIC CLINIC WELFARE BENEFITS PLAN
Plan identification number	501

CAPITAL ORTHOPAEDIC CLINIC WELFARE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

CAPITAL ORTHOPAEDIC AND SPORTS MEDICINE CENTER has sponsored the creation of one or more 401k plans.

Company Name: CAPITAL ORTHOPAEDIC AND SPORTS MEDICINE CENTER

Employer identification number (EIN): 203941865

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CAPITAL ORTHOPAEDIC CLINIC WELFARE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2024-06-01 NEAL BUMPUS
501 2023-06-01
501 2023-06-01 NEAL BUMPUS

Form 5500 Responses for CAPITAL ORTHOPAEDIC CLINIC WELFARE BENEFITS PLAN

2023: CAPITAL ORTHOPAEDIC CLINIC WELFARE BENEFITS PLAN 2023 form 5500 responses
2023-06-01	Type of plan entity	Single employer plan
2023-06-01	First time form 5500 has been submitted	Yes
2023-06-01	Submission has been amended	No
2023-06-01	This submission is the final filing	No
2023-06-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-06-01	Plan is a collectively bargained plan	No
2023-06-01	Plan funding arrangement – Insurance	Yes
2023-06-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-06-01	Plan benefit arrangement – Insurance	Yes
2023-06-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF MS, INC. (National Association of Insurance Commissioners NAIC id number: 60111 )

Policy contract number

017139

Policy instance

Insurance contract or identification number	017139
Number of Individuals Covered	204
Insurance policy start date	2023-06-01
Insurance policy end date	2024-05-31
Total amount of commissions paid to insurance broker	USD $31,536
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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	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
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?	Yes

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

960635

Policy instance

Insurance contract or identification number	960635
Number of Individuals Covered	113
Insurance policy start date	2023-06-01
Insurance policy end date	2024-05-31
Total amount of commissions paid to insurance broker	USD $7,545
Total amount of fees paid to insurance company	USD $1,703
Are there contracts with allocated funds for individual policies?	0
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	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 $75,453
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

20267788

Policy instance

Insurance contract or identification number	20267788
Number of Individuals Covered	117
Insurance policy start date	2023-06-01
Insurance policy end date	2024-05-31
Total amount of commissions paid to insurance broker	USD $17,730
Total amount of fees paid to insurance company	USD $180
Are there contracts with allocated funds for individual policies?	0
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
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 $127,655
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60049 )

Policy contract number

E4436515

Policy instance

Insurance contract or identification number	E4436515
Number of Individuals Covered	41
Insurance policy start date	2023-06-01
Insurance policy end date	2024-05-31
Total amount of commissions paid to insurance broker	USD $10,578
Total amount of fees paid to insurance company	USD $4,479
Are there contracts with allocated funds for individual policies?	0
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
Other welfare benefits provided	VOLUNTARY WORKSITE
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 $39,926
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

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Company Name:	CAPITAL ORTHOPAEDIC AND SPORTS MEDICINE CENTER
Employer identification number (EIN):	203941865
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)

Plan id#	Filing Submission Date	Name of Administrator
501	2024-06-01	NEAL BUMPUS
501	2023-06-01
501	2023-06-01	NEAL BUMPUS