401k Plan data: BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN plan

BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN 401k Plan overview

Plan Name	BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN
Plan identification number	506

BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Temporary disability (accident and sickness) Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

BONE & JOINT CLINIC, S.C. has sponsored the creation of one or more 401k plans.

Company Name: BONE & JOINT CLINIC, S.C.

Employer identification number (EIN): 391130341

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2016-01-01 LARRY SPONDER
506 2015-01-01 LARRY SPONDER
506 2012-01-01 LARRY SPONDER

Plan id#	Filing Submission Date	Name of Administrator
506	2016-01-01	LARRY SPONDER
506	2015-01-01	LARRY SPONDER
506	2012-01-01	LARRY SPONDER

Plan Statistics for BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN

401k plan membership statisitcs for BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN

Measure Date Value
2016: BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 117
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 0
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 0
Total of all active and inactive participants 2016-01-01 0
2015: BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 107
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 115
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 0
Total of all active and inactive participants 2015-01-01 115
2012: BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 96
Total of all active and inactive participants 2012-01-01 96
Total participants 2012-01-01 96
Number of employers contributing to the scheme 2012-01-01 0

Measure	Date	Value
2016: BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	117
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	0
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	0
Total of all active and inactive participants	2016-01-01	0
2015: BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	107
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	115
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	0
Total of all active and inactive participants	2015-01-01	115
2012: BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	96
Total of all active and inactive participants	2012-01-01	96
Total participants	2012-01-01	96
Number of employers contributing to the scheme	2012-01-01	0

Form 5500 Responses for BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN

2016: BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY 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	Yes
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 benefit arrangement – Insurance	Yes
2015: BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY 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 benefit arrangement – Insurance	Yes
2012: BONE & JOINT CLINIC, S.C. SHORT TERM DISABILITY PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	First time form 5500 has been submitted	Yes
2012-01-01	Submission has been amended	Yes
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SOK601317

Policy instance

Insurance contract or identification number	SOK601317
Number of Individuals Covered	115
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $2,948
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?	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	Yes
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 $39,970
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,948
Insurance broker organization code?	3
Insurance broker name	ANSAY & ASSOCIATES LLC

LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 65498 )

Policy contract number

SGD602096

Policy instance

Insurance contract or identification number	SGD602096
Number of Individuals Covered	96
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $2,438
Total amount of fees paid to insurance company	USD $0
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,758
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,438
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	BENEFIT PARTNERS LLC

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Company Name:	BONE & JOINT CLINIC, S.C.
Employer identification number (EIN):	391130341
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)