401k Plan data: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN plan

SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 401k Plan overview

Plan Name	SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN
Plan identification number	001

SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

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.
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

SHORELINE OPHTHALMOLOGY, PC has sponsored the creation of one or more 401k plans.

Company Name: SHORELINE OPHTHALMOLOGY, PC

Employer identification number (EIN): 383245641

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2019-01-01
001 2018-01-01 JOHN N. OLTEAN, D.O. 2019-10-03
001 2017-01-01
001 2016-01-01
001 2015-01-01
001 2014-01-01 JOHN N. OLTEAN, D.O.
001 2013-01-01 JOHN N. OLTEAN, D. CO. 2014-07-22
001 2012-01-01 JOHN N. OLTEAN, D. CO. 2013-07-23
001 2011-01-01 JOHN N. OLTEAN, D. CO. 2012-09-18
001 2010-01-01 JOHN N OLTEAN, D.O. 2011-09-12 JOHN N OLTEAN, D.O. 2011-09-12

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2019-01-01
001	2018-01-01	JOHN N. OLTEAN, D.O.	2019-10-03
001	2017-01-01
001	2016-01-01
001	2015-01-01
001	2014-01-01	JOHN N. OLTEAN, D.O.
001	2013-01-01	JOHN N. OLTEAN, D. CO.	2014-07-22
001	2012-01-01	JOHN N. OLTEAN, D. CO.	2013-07-23
001	2011-01-01	JOHN N. OLTEAN, D. CO.	2012-09-18
001	2010-01-01	JOHN N OLTEAN, D.O.	2011-09-12	JOHN N OLTEAN, D.O.	2011-09-12

Plan Statistics for SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN

401k plan membership statisitcs for SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN

Measure Date Value
2019: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 146
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 0
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 0
Number of participants with account balances 2019-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 0
2018: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 155
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 125
Number of retired or separated participants receiving benefits 2018-01-01 10
Number of other retired or separated participants entitled to future benefits 2018-01-01 14
Total of all active and inactive participants 2018-01-01 149
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 149
Number of participants with account balances 2018-01-01 149
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 4
2017: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 148
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 117
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 29
Total of all active and inactive participants 2017-01-01 146
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 146
Number of participants with account balances 2017-01-01 146
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 6
2016: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 141
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 123
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 18
Total of all active and inactive participants 2016-01-01 141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 141
Number of participants with account balances 2016-01-01 141
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 1
2015: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 144
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 120
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 16
Total of all active and inactive participants 2015-01-01 136
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 136
Number of participants with account balances 2015-01-01 136
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 4
2014: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 135
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 115
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 17
Total of all active and inactive participants 2014-01-01 132
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 132
Number of participants with account balances 2014-01-01 132
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 4

Measure	Date	Value
2019: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	146
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	0
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	0
Number of participants with account balances	2019-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	0
2018: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	155
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	125
Number of retired or separated participants receiving benefits	2018-01-01	10
Number of other retired or separated participants entitled to future benefits	2018-01-01	14
Total of all active and inactive participants	2018-01-01	149
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	149
Number of participants with account balances	2018-01-01	149
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	4
2017: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	148
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	117
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	29
Total of all active and inactive participants	2017-01-01	146
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	146
Number of participants with account balances	2017-01-01	146
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	6
2016: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	123
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	18
Total of all active and inactive participants	2016-01-01	141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	141
Number of participants with account balances	2016-01-01	141
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	1
2015: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	144
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	120
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	16
Total of all active and inactive participants	2015-01-01	136
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	136
Number of participants with account balances	2015-01-01	136
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	4
2014: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	135
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	115
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	17
Total of all active and inactive participants	2014-01-01	132
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	132
Number of participants with account balances	2014-01-01	132
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	4

Financial Data on SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN

Measure	Date	Value
2019 : SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-01-24	$0
Total transfer of assets from this plan	2019-01-24	$12,624,178
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-01-24	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-01-24	$0
Total income from all sources (including contributions)	2019-01-24	$587,322
Total loss/gain on sale of assets	2019-01-24	$0
Total of all expenses incurred	2019-01-24	$47,701
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-01-24	$47,701
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-01-24	$15,795
Value of total assets at end of year	2019-01-24	$0
Value of total assets at beginning of year	2019-01-24	$12,084,557
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-01-24	$0
Total interest from all sources	2019-01-24	$0
Total dividends received (eg from common stock, registered investment company shares)	2019-01-24	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2019-01-24	Yes
Value of any plan assets that reverted to the employer resulting from resoluton to terminate the plan	2019-01-24	$0
Was this plan covered by a fidelity bond	2019-01-24	Yes
Value of fidelity bond cover	2019-01-24	$500,000
If this is an individual account plan, was there a blackout period	2019-01-24	Yes
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-01-24	$0
Were there any nonexempt tranactions with any party-in-interest	2019-01-24	No
Contributions received from participants	2019-01-24	$15,795
Participant contributions at end of year	2019-01-24	$0
Participant contributions at beginning of year	2019-01-24	$113,502
Other income not declared elsewhere	2019-01-24	$-15,849
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-01-24	No
Value of net income/loss	2019-01-24	$539,621
Value of net assets at end of year (total assets less liabilities)	2019-01-24	$0
Value of net assets at beginning of year (total assets less liabilities)	2019-01-24	$12,084,557
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-01-24	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-01-24	No
Were any leases to which the plan was party in default or uncollectible	2019-01-24	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-01-24	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-01-24	$11,420,801
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-01-24	$407,539
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-01-24	$587,376
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-01-24	No
Was there a failure to transmit to the plan any participant contributions	2019-01-24	No
Has the plan failed to provide any benefit when due under the plan	2019-01-24	No
Employer contributions (assets) at beginning of year	2019-01-24	$142,715
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-01-24	$47,701
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	2019-01-24	Yes
Did the plan have assets held for investment	2019-01-24	No
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	2019-01-24	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-01-24	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-01-24	Yes
Opinion of an independent qualified public accountant for this plan	2019-01-24	Disclaimer
Accountancy firm name	2019-01-24	BAIRD, COTTER & BISHOP PC
Accountancy firm EIN	2019-01-24	381995866
2018 : SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total income from all sources (including contributions)	2018-12-31	$-94,450
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$345,415
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$295,644
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$758,864
Value of total assets at end of year	2018-12-31	$12,084,557
Value of total assets at beginning of year	2018-12-31	$12,524,422
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$49,771
Total interest from all sources	2018-12-31	$10,336
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2018-12-31	No
Administrative expenses professional fees incurred	2018-12-31	$11,910
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$500,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$453,387
Participant contributions at end of year	2018-12-31	$113,502
Participant contributions at beginning of year	2018-12-31	$172,554
Participant contributions at end of year	2018-12-31	$0
Participant contributions at beginning of year	2018-12-31	$2,500
Other income not declared elsewhere	2018-12-31	$7,546
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$-439,865
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$12,084,557
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$12,524,422
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Investment advisory and management fees	2018-12-31	$27,867
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$11,420,801
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2018-12-31	$11,649,670
Interest on participant loans	2018-12-31	$10,336
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-12-31	$407,539
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-12-31	$361,364
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-871,196
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Contributions received in cash from employer	2018-12-31	$305,477
Employer contributions (assets) at end of year	2018-12-31	$142,715
Employer contributions (assets) at beginning of year	2018-12-31	$338,334
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$295,644
Contract administrator fees	2018-12-31	$9,994
Did the plan have assets held for investment	2018-12-31	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	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	BAIRD, COTTER & BISHOP PC
Accountancy firm EIN	2018-12-31	381995866
2017 : SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2017 401k financial data
Total unrealized appreciation/depreciation of assets	2017-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2017-12-31	$0
Total income from all sources (including contributions)	2017-12-31	$2,750,129
Total loss/gain on sale of assets	2017-12-31	$0
Total of all expenses incurred	2017-12-31	$451,820
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$389,653
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$922,235
Value of total assets at end of year	2017-12-31	$12,524,422
Value of total assets at beginning of year	2017-12-31	$10,226,113
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$62,167
Total interest from all sources	2017-12-31	$7,642
Total dividends received (eg from common stock, registered investment company shares)	2017-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Administrative expenses professional fees incurred	2017-12-31	$15,055
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$500,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$421,267
Participant contributions at end of year	2017-12-31	$172,554
Participant contributions at beginning of year	2017-12-31	$128,652
Participant contributions at end of year	2017-12-31	$2,500
Participant contributions at beginning of year	2017-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2017-12-31	$42,634
Other income not declared elsewhere	2017-12-31	$5,143
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Value of net income/loss	2017-12-31	$2,298,309
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$12,524,422
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$10,226,113
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2017-12-31	$11,649,670
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2017-12-31	$9,463,072
Interest on participant loans	2017-12-31	$7,642
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2017-12-31	$361,364
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2017-12-31	$343,432
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2017-12-31	$1,815,109
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	No
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Contributions received in cash from employer	2017-12-31	$458,334
Employer contributions (assets) at end of year	2017-12-31	$338,334
Employer contributions (assets) at beginning of year	2017-12-31	$290,957
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$389,653
Contract administrator fees	2017-12-31	$47,112
Did the plan have assets held for investment	2017-12-31	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	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	BAIRD, COTTER & BISHOP PC
Accountancy firm EIN	2017-12-31	381995866
2016 : SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2016 401k financial data
Total unrealized appreciation/depreciation of assets	2016-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2016-12-31	$0
Total income from all sources (including contributions)	2016-12-31	$1,402,926
Total loss/gain on sale of assets	2016-12-31	$0
Total of all expenses incurred	2016-12-31	$602,857
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$532,199
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$789,915
Value of total assets at end of year	2016-12-31	$10,226,113
Value of total assets at beginning of year	2016-12-31	$9,426,044
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$70,658
Total interest from all sources	2016-12-31	$6,541
Total dividends received (eg from common stock, registered investment company shares)	2016-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Administrative expenses professional fees incurred	2016-12-31	$17,732
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$500,000
If this is an individual account plan, was there a blackout period	2016-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$391,820
Participant contributions at end of year	2016-12-31	$128,652
Participant contributions at beginning of year	2016-12-31	$121,670
Participant contributions at end of year	2016-12-31	$0
Participant contributions at beginning of year	2016-12-31	$14,864
Income. Received or receivable in cash from other sources (including rollovers)	2016-12-31	$17,212
Other income not declared elsewhere	2016-12-31	$6,350
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Value of net income/loss	2016-12-31	$800,069
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$10,226,113
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$9,426,044
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2016-12-31	$9,463,072
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2016-12-31	$8,684,937
Interest on participant loans	2016-12-31	$6,541
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2016-12-31	$343,432
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2016-12-31	$326,788
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2016-12-31	$600,120
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	No
Was there a failure to transmit to the plan any participant contributions	2016-12-31	No
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Contributions received in cash from employer	2016-12-31	$380,883
Employer contributions (assets) at end of year	2016-12-31	$290,957
Employer contributions (assets) at beginning of year	2016-12-31	$277,785
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$532,199
Contract administrator fees	2016-12-31	$52,926
Did the plan have assets held for investment	2016-12-31	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	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2016-12-31	Disclaimer
Accountancy firm name	2016-12-31	BAIRD, COTTER & BISHOP PC
Accountancy firm EIN	2016-12-31	381995866
2015 : SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total income from all sources (including contributions)	2015-12-31	$799,407
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$665,781
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$597,317
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$742,577
Value of total assets at end of year	2015-12-31	$9,426,044
Value of total assets at beginning of year	2015-12-31	$9,292,418
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$68,464
Total interest from all sources	2015-12-31	$4,112
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Administrative expenses professional fees incurred	2015-12-31	$16,345
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$500,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$368,634
Participant contributions at end of year	2015-12-31	$121,670
Participant contributions at beginning of year	2015-12-31	$30,365
Participant contributions at end of year	2015-12-31	$14,864
Participant contributions at beginning of year	2015-12-31	$4,750
Other income not declared elsewhere	2015-12-31	$5,197
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$133,626
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$9,426,044
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$9,292,418
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2015-12-31	$8,684,937
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$8,585,981
Interest on participant loans	2015-12-31	$4,112
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-12-31	$326,788
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$318,160
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$47,521
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	No
Was there a failure to transmit to the plan any participant contributions	2015-12-31	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$373,943
Employer contributions (assets) at end of year	2015-12-31	$277,785
Employer contributions (assets) at beginning of year	2015-12-31	$353,162
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$597,317
Contract administrator fees	2015-12-31	$52,119
Did the plan have assets held for investment	2015-12-31	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	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	BAIRD, COTTER & BISHOP PC
Accountancy firm EIN	2015-12-31	381995866
2014 : SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total income from all sources (including contributions)	2014-12-31	$1,194,569
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$278,798
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$215,757
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$720,786
Value of total assets at end of year	2014-12-31	$9,292,418
Value of total assets at beginning of year	2014-12-31	$8,376,647
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$63,041
Total interest from all sources	2014-12-31	$242
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Administrative expenses professional fees incurred	2014-12-31	$13,037
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$250,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$364,624
Participant contributions at end of year	2014-12-31	$30,365
Participant contributions at beginning of year	2014-12-31	$0
Participant contributions at end of year	2014-12-31	$4,750
Participant contributions at beginning of year	2014-12-31	$8,107
Income. Received or receivable in cash from other sources (including rollovers)	2014-12-31	$3,000
Other income not declared elsewhere	2014-12-31	$4,098
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Value of net income/loss	2014-12-31	$915,771
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$9,292,418
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$8,376,647
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2014-12-31	$8,585,981
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2014-12-31	$7,824,429
Interest on participant loans	2014-12-31	$242
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$318,160
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$190,619
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$469,443
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	No
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$353,162
Employer contributions (assets) at end of year	2014-12-31	$353,162
Employer contributions (assets) at beginning of year	2014-12-31	$353,492
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$215,757
Contract administrator fees	2014-12-31	$50,004
Did the plan have assets held for investment	2014-12-31	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	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	BAIRD, COTTER & BISHOP PC
Accountancy firm EIN	2014-12-31	381995866

Form 5500 Responses for SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN

2019: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	Yes
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: SHORELINE OPHTHALMOLOGY, PLC 401(K) PROFIT SHARING PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: SHORELINE OPHTHALMOLOGY, PLC 401(K) 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

Insurance Providers Used on plan

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

GAP-B2-AQ3D

Policy instance

Insurance contract or identification number	GAP-B2-AQ3D
Number of Individuals Covered	0
Insurance policy start date	2019-01-01
Insurance policy end date	2019-01-24
Total amount of commissions paid to insurance broker	USD $0
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

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

GAP-B2-AQ3D

Policy instance

Insurance contract or identification number	GAP-B2-AQ3D
Number of Individuals Covered	149
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $264
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 $264
Insurance broker organization code?	4

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

GAP-B2-AQ3D

Policy instance

Insurance contract or identification number	GAP-B2-AQ3D
Number of Individuals Covered	146
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $1,578
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 $1,578
Insurance broker organization code?	4
Insurance broker name	ROYAL ALLIANCE ASSOC INC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

GAP-B2-AQ3D

Policy instance

Insurance contract or identification number	GAP-B2-AQ3D
Number of Individuals Covered	136
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,975
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 $1,975
Insurance broker organization code?	4
Insurance broker name	ROYAL ALLIANCE ASSOC INC

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

GAP-B2-AQ3D

Policy instance

Insurance contract or identification number	GAP-B2-AQ3D
Number of Individuals Covered	132
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $1,257
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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 $1,257
Insurance broker organization code?	4
Insurance broker name	ROYAL ALLIANCE ASSOC INC

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Company Name:	SHORELINE OPHTHALMOLOGY, PC
Employer identification number (EIN):	383245641
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)