401k Plan data: ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN plan

ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN 401k Plan overview

Plan Name	ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN
Plan identification number	509

ST. CLOUD MEDICAL GROUP P.A. 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

ST. CLOUD MEDICAL GROUP, PA has sponsored the creation of one or more 401k plans.

Company Name: ST. CLOUD MEDICAL GROUP, PA

Employer identification number (EIN): 410986131

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
509 2016-01-01 KRISTEN GUTHMILLER
509 2015-08-01 CELESTE GARDNER
509 2014-08-01 CELESTE GARDNER
509 2014-01-01 CELESTE GARDNER

Plan id#	Filing Submission Date	Name of Administrator
509	2016-01-01	KRISTEN GUTHMILLER
509	2015-08-01	CELESTE GARDNER
509	2014-08-01	CELESTE GARDNER
509	2014-01-01	CELESTE GARDNER

Plan Statistics for ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN

401k plan membership statisitcs for ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN

Measure Date Value
2016: ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 104
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 93
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 93
2015: ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year 2015-08-01 117
Total number of active participants reported on line 7a of the Form 5500 2015-08-01 112
Number of retired or separated participants receiving benefits 2015-08-01 0
Number of other retired or separated participants entitled to future benefits 2015-08-01 0
Total of all active and inactive participants 2015-08-01 112
2014: ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN 2014 401k membership
Total participants, beginning-of-year 2014-08-01 116
Total number of active participants reported on line 7a of the Form 5500 2014-08-01 112
Number of retired or separated participants receiving benefits 2014-08-01 0
Number of other retired or separated participants entitled to future benefits 2014-08-01 0
Total of all active and inactive participants 2014-08-01 112
Total participants, beginning-of-year 2014-01-01 108
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 107
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 0
Total of all active and inactive participants 2014-01-01 107

Measure	Date	Value
2016: ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	104
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	93
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	93
2015: ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year	2015-08-01	117
Total number of active participants reported on line 7a of the Form 5500	2015-08-01	112
Number of retired or separated participants receiving benefits	2015-08-01	0
Number of other retired or separated participants entitled to future benefits	2015-08-01	0
Total of all active and inactive participants	2015-08-01	112
2014: ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN 2014 401k membership
Total participants, beginning-of-year	2014-08-01	116
Total number of active participants reported on line 7a of the Form 5500	2014-08-01	112
Number of retired or separated participants receiving benefits	2014-08-01	0
Number of other retired or separated participants entitled to future benefits	2014-08-01	0
Total of all active and inactive participants	2014-08-01	112
Total participants, beginning-of-year	2014-01-01	108
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	107
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	0
Total of all active and inactive participants	2014-01-01	107

Form 5500 Responses for ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN

2016: ST. CLOUD MEDICAL GROUP P.A. 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	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 benefit arrangement – Insurance	Yes
2015: ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN 2015 form 5500 responses
2015-08-01	Type of plan entity	Single employer plan
2015-08-01	Submission has been amended	No
2015-08-01	This submission is the final filing	No
2015-08-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2015-08-01	Plan is a collectively bargained plan	No
2015-08-01	Plan funding arrangement – Insurance	Yes
2015-08-01	Plan benefit arrangement – Insurance	Yes
2014: ST. CLOUD MEDICAL GROUP P.A. SHORT-TERM DISABILITY PLAN 2014 form 5500 responses
2014-08-01	Type of plan entity	Single employer plan
2014-08-01	Submission has been amended	No
2014-08-01	This submission is the final filing	No
2014-08-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-08-01	Plan is a collectively bargained plan	No
2014-08-01	Plan funding arrangement – Insurance	Yes
2014-08-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	First time form 5500 has been submitted	Yes
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)	Yes
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

STD09020

Policy instance

Insurance contract or identification number	STD09020
Number of Individuals Covered	113
Insurance policy start date	2015-08-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $1,677
Total amount of fees paid to insurance company	USD $75
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 $25,072
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,677
Insurance broker organization code?	3
Amount paid for insurance broker fees	75
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEE
Insurance broker name	MEDICAL GROUP INSURANCE SERVICES

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

Policy contract number

STD09020

Policy instance

Insurance contract or identification number	STD09020
Number of Individuals Covered	114
Insurance policy start date	2014-08-01
Insurance policy end date	2015-07-31
Total amount of commissions paid to insurance broker	USD $3,695
Total amount of fees paid to insurance company	USD $60
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 $49,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,695
Insurance broker organization code?	3
Amount paid for insurance broker fees	60
Additional information about fees paid to insurance broker	ADMINISTRATIVE FEE
Insurance broker name	MEDICAL GROUP INSURANCE SERVICES

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

Policy contract number

STD09020

Policy instance

Insurance contract or identification number	STD09020
Number of Individuals Covered	111
Insurance policy start date	2014-01-01
Insurance policy end date	2014-07-31
Total amount of commissions paid to insurance broker	USD $2,001
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 $26,677
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,443
Insurance broker organization code?	3
Insurance broker name	NORTH RISK PARTNERS, LLC

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Company Name:	ST. CLOUD MEDICAL GROUP, PA
Employer identification number (EIN):	410986131
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)