401k Plan data: CAPITOL PAIN INSTITUTE 401(K) PLAN plan

CAPITOL PAIN INSTITUTE 401(K) PLAN 401k Plan overview

Plan Name	CAPITOL PAIN INSTITUTE 401(K) PLAN
Plan identification number	001

CAPITOL PAIN INSTITUTE 401(K) 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.
Plan provides for automatic enrollment in plan that has employee contributions deducted from payroll.
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.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

CAPITOL PAIN INSTITUTE has sponsored the creation of one or more 401k plans.

Company Name: CAPITOL PAIN INSTITUTE

Employer identification number (EIN): 208370906

NAIC Classification: 621112
NAIC Description: Offices of Physicians, Mental Health Specialists

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CAPITOL PAIN INSTITUTE 401(K) 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 2019-01-01 PHIL TISUE 2020-09-11
001 2018-01-01 PHIL TISUE 2019-07-31
001 2017-01-01 PHIL TISUE 2018-10-05

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2022-01-01
001	2021-01-01
001	2020-01-01
001	2019-01-01	PHIL TISUE	2020-09-11
001	2018-01-01	PHIL TISUE	2019-07-31
001	2017-01-01	PHIL TISUE	2018-10-05

Plan Statistics for CAPITOL PAIN INSTITUTE 401(K) PLAN

401k plan membership statisitcs for CAPITOL PAIN INSTITUTE 401(K) PLAN

Measure Date Value
2022: CAPITOL PAIN INSTITUTE 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 247
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 140
Number of retired or separated participants receiving benefits 2022-01-01 5
Number of other retired or separated participants entitled to future benefits 2022-01-01 49
Total of all active and inactive participants 2022-01-01 194
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 194
Number of participants with account balances 2022-01-01 180
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 15
2021: CAPITOL PAIN INSTITUTE 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 175
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 129
Number of retired or separated participants receiving benefits 2021-01-01 24
Number of other retired or separated participants entitled to future benefits 2021-01-01 92
Total of all active and inactive participants 2021-01-01 245
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 245
Number of participants with account balances 2021-01-01 240
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 14
2020: CAPITOL PAIN INSTITUTE 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 132
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 40
Total of all active and inactive participants 2020-01-01 172
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 172
Number of participants with account balances 2020-01-01 145
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 21

Measure	Date	Value
2022: CAPITOL PAIN INSTITUTE 401(K) PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	247
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	140
Number of retired or separated participants receiving benefits	2022-01-01	5
Number of other retired or separated participants entitled to future benefits	2022-01-01	49
Total of all active and inactive participants	2022-01-01	194
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	194
Number of participants with account balances	2022-01-01	180
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	15
2021: CAPITOL PAIN INSTITUTE 401(K) PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	175
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	129
Number of retired or separated participants receiving benefits	2021-01-01	24
Number of other retired or separated participants entitled to future benefits	2021-01-01	92
Total of all active and inactive participants	2021-01-01	245
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	245
Number of participants with account balances	2021-01-01	240
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	14
2020: CAPITOL PAIN INSTITUTE 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	132
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	40
Total of all active and inactive participants	2020-01-01	172
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	172
Number of participants with account balances	2020-01-01	145
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	21

Financial Data on CAPITOL PAIN INSTITUTE 401(K) PLAN

Measure	Date	Value
2022 : CAPITOL PAIN INSTITUTE 401(K) PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$339,839
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$179,301
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$151,462
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$745,900
Value of total assets at end of year	2022-12-31	$2,318,148
Value of total assets at beginning of year	2022-12-31	$2,157,610
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$27,839
Total interest from all sources	2022-12-31	$2,106
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
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$500,000
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	$542,753
Participant contributions at end of year	2022-12-31	$9,113
Participant contributions at beginning of year	2022-12-31	$9,342
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$17,194
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	$160,538
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$2,318,148
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$2,157,610
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 pooled separate accounts at end of year	2022-12-31	$2,204,645
Value of interest in pooled separate accounts at beginning of year	2022-12-31	$2,060,346
Interest on participant loans	2022-12-31	$366
Interest earned on other investments	2022-12-31	$1,740
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2022-12-31	$104,390
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2022-12-31	$87,922
Net investment gain/loss from pooled separate accounts	2022-12-31	$-408,167
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	No
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	$185,953
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$151,462
Contract administrator fees	2022-12-31	$27,839
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	COULTER & JUSTUS
Accountancy firm EIN	2022-12-31	621532536
2021 : CAPITOL PAIN INSTITUTE 401(K) PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$923,773
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$168,149
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$150,205
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$693,930
Value of total assets at end of year	2021-12-31	$2,157,610
Value of total assets at beginning of year	2021-12-31	$1,401,986
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$17,944
Total interest from all sources	2021-12-31	$2,398
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
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$500,000
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	$378,989
Participant contributions at end of year	2021-12-31	$9,342
Participant contributions at beginning 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	$755,624
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$2,157,610
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$1,401,986
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 pooled separate accounts at end of year	2021-12-31	$2,060,346
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$1,380,757
Interest on participant loans	2021-12-31	$1,738
Interest earned on other investments	2021-12-31	$660
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2021-12-31	$87,922
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2021-12-31	$21,229
Net investment gain/loss from pooled separate accounts	2021-12-31	$227,445
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	No
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	$314,941
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$150,205
Contract administrator fees	2021-12-31	$17,944
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	COULTER & JUSTUS
Accountancy firm EIN	2021-12-31	621532536
2020 : CAPITOL PAIN INSTITUTE 401(K) PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$713,614
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$63,671
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$56,687
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$481,051
Value of total assets at end of year	2020-12-31	$1,401,986
Value of total assets at beginning of year	2020-12-31	$752,043
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$6,984
Total interest from all sources	2020-12-31	$253
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
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	$500,000
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	$299,644
Participant contributions at end of year	2020-12-31	$0
Participant contributions at beginning of year	2020-12-31	$17,131
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$82,505
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	$649,943
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$1,401,986
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$752,043
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 pooled separate accounts at end of year	2020-12-31	$1,380,757
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$728,704
Interest on participant loans	2020-12-31	$127
Interest earned on other investments	2020-12-31	$126
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-12-31	$21,229
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-12-31	$4,113
Net investment gain/loss from pooled separate accounts	2020-12-31	$232,310
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	No
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	$98,902
Employer contributions (assets) at end of year	2020-12-31	$0
Employer contributions (assets) at beginning of year	2020-12-31	$2,095
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$56,687
Contract administrator fees	2020-12-31	$6,984
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2020-12-31	No
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	Unqualified
Accountancy firm name	2020-12-31	COULTER & JUSTUS
Accountancy firm EIN	2020-12-31	621532536

Form 5500 Responses for CAPITOL PAIN INSTITUTE 401(K) PLAN

2022: CAPITOL PAIN INSTITUTE 401(K) PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: CAPITOL PAIN INSTITUTE 401(K) PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: CAPITOL PAIN INSTITUTE 401(K) PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70688 )

Policy contract number

932339-00105

Policy instance

Insurance contract or identification number	932339-00105
Number of Individuals Covered	194
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $7,434
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?	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 $6,766
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70688 )

Policy contract number

932339-00105

Policy instance

Insurance contract or identification number	932339-00105
Number of Individuals Covered	244
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $5,810
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	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 $2,905
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

TRANSAMERICA FINANCIAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70688 )

Policy contract number

932339-00105

Policy instance

Insurance contract or identification number	932339-00105
Number of Individuals Covered	172
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $3,510
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	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 $2,507
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3

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Company Name:	CAPITOL PAIN INSTITUTE
Employer identification number (EIN):	208370906
NAIC Classification:	621112
NAIC Description:	Offices of Physicians, Mental Health Specialists