401k Plan data: ACUTE CARE SURGERY MEDICAL GROUP, INC. HEALTH AND WELFARE PLAN plan

ACUTE CARE SURGERY MEDICAL GROUP, INC. HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	ACUTE CARE SURGERY MEDICAL GROUP, INC. HEALTH AND WELFARE PLAN
Plan identification number	501

ACUTE CARE SURGERY MEDICAL GROUP, INC. HEALTH AND WELFARE 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)

401k Sponsoring company profile

ACUTE CARE SURGERY MEDICAL GROUP, I has sponsored the creation of one or more 401k plans.

Company Name: ACUTE CARE SURGERY MEDICAL GROUP, I

Employer identification number (EIN): 261491885

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ACUTE CARE SURGERY MEDICAL GROUP, INC. HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 KATHLEEN COLE 2023-08-02

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	KATHLEEN COLE	2023-08-02

Plan Statistics for ACUTE CARE SURGERY MEDICAL GROUP, INC. HEALTH AND WELFARE PLAN

401k plan membership statisitcs for ACUTE CARE SURGERY MEDICAL GROUP, INC. HEALTH AND WELFARE PLAN

Measure Date Value
2022: ACUTE CARE SURGERY MEDICAL GROUP, INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 130
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 208
Number of retired or separated participants receiving benefits 2022-01-01 2
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 210
Number of employers contributing to the scheme 2022-01-01 0

Measure	Date	Value
2022: ACUTE CARE SURGERY MEDICAL GROUP, INC. HEALTH AND WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	130
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	208
Number of retired or separated participants receiving benefits	2022-01-01	2
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	210
Number of employers contributing to the scheme	2022-01-01	0

Form 5500 Responses for ACUTE CARE SURGERY MEDICAL GROUP, INC. HEALTH AND WELFARE PLAN

2022: ACUTE CARE SURGERY MEDICAL GROUP, INC. HEALTH AND WELFARE PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	First time form 5500 has been submitted	Yes
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0040871

Policy instance

Insurance contract or identification number	W0040871
Number of Individuals Covered	172
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $43,084
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,308,383
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $43,084
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

727982

Policy instance

Insurance contract or identification number	727982
Number of Individuals Covered	13
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $9,316
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $145,985
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,312
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10089391001

Policy instance

Insurance contract or identification number	10089391001
Number of Individuals Covered	231
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,341
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,341
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

5392870

Policy instance

Insurance contract or identification number	5392870
Number of Individuals Covered	346
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $3,125
Total amount of fees paid to insurance company	USD $57
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $91,422
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,125
Amount paid for insurance broker fees	57
Additional information about fees paid to insurance broker	NON-MONETARY COMPENSATION
Insurance broker organization code?	3

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10268607

Policy instance

Insurance contract or identification number	10268607
Number of Individuals Covered	118
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $12,936
Total amount of fees paid to insurance company	USD $9,202
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $253,345
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $12,936
Amount paid for insurance broker fees	9202
Additional information about fees paid to insurance broker	BROKER BONUS
Insurance broker organization code?	3

Potentially related plans

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Company Name:	ACUTE CARE SURGERY MEDICAL GROUP, I
Employer identification number (EIN):	261491885
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)