401k Plan data: ANKLE AND FOOT ASSOCIATES HEALTH & WELFARE BENEFIT PLAN plan

ANKLE AND FOOT ASSOCIATES HEALTH & WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	ANKLE AND FOOT ASSOCIATES HEALTH & WELFARE BENEFIT PLAN
Plan identification number	501

ANKLE AND FOOT ASSOCIATES HEALTH & WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

ANKLE & FOOT SURGERY CENTER, LLC has sponsored the creation of one or more 401k plans.

Company Name: ANKLE & FOOT SURGERY CENTER, LLC

Employer identification number (EIN): 582620410

NAIC Classification: 621391
NAIC Description: Offices of Podiatrists

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ANKLE AND FOOT ASSOCIATES HEALTH & WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-01-01 DAVID MURPHY 2021-09-23

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2020-01-01	DAVID MURPHY	2021-09-23

Plan Statistics for ANKLE AND FOOT ASSOCIATES HEALTH & WELFARE BENEFIT PLAN

401k plan membership statisitcs for ANKLE AND FOOT ASSOCIATES HEALTH & WELFARE BENEFIT PLAN

Measure Date Value
2020: ANKLE AND FOOT ASSOCIATES HEALTH & WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 109
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 105
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 0
Total of all active and inactive participants 2020-01-01 105

Measure	Date	Value
2020: ANKLE AND FOOT ASSOCIATES HEALTH & WELFARE BENEFIT PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	109
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	105
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	0
Total of all active and inactive participants	2020-01-01	105

Form 5500 Responses for ANKLE AND FOOT ASSOCIATES HEALTH & WELFARE BENEFIT PLAN

2020: ANKLE AND FOOT ASSOCIATES HEALTH & WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	First time form 5500 has been submitted	Yes
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 – General assets of the sponsor	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

802852

Policy instance

Insurance contract or identification number	802852
Number of Individuals Covered	107
Insurance policy start date	2020-01-01
Insurance policy end date	2020-06-30
Total amount of commissions paid to insurance broker	USD $218
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
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 $2,616
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $218
Insurance broker organization code?	3

GREATER GEORGIA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 97217 )

Policy contract number

CM10000190

Policy instance

Insurance contract or identification number	CM10000190
Number of Individuals Covered	105
Insurance policy start date	2020-07-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $276
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
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 $2,182
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $276
Insurance broker organization code?	3

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

L00591

Policy instance

Insurance contract or identification number	L00591
Number of Individuals Covered	109
Insurance policy start date	2020-07-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $1,875
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	Yes
Vision Insurance Welfare Benefit	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $26,371
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,875
Insurance broker organization code?	3

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Company Name:	ANKLE & FOOT SURGERY CENTER, LLC
Employer identification number (EIN):	582620410
NAIC Classification:	621391
NAIC Description:	Offices of Podiatrists