401k Plan data: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN plan

UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 401k Plan overview

Plan Name	UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN
Plan identification number	003

UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
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.
Plan provides for automatic enrollment in plan that has employee contributions deducted from payroll.
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.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

UNIVERSITY SURGICAL ASSOCIATES, PLLC. has sponsored the creation of one or more 401k plans.

Company Name: UNIVERSITY SURGICAL ASSOCIATES, PLLC.

Employer identification number (EIN): 621658774

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
003 2022-01-01
003 2021-01-01
003 2020-01-01
003 2020-01-01
003 2009-01-01 CRAIG SARINE

Plan Statistics for UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN

401k plan membership statisitcs for UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN

Measure Date Value
2022: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 330
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 169
Number of retired or separated participants receiving benefits 2022-01-01 58
Number of other retired or separated participants entitled to future benefits 2022-01-01 100
Total of all active and inactive participants 2022-01-01 327
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 327
Number of participants with account balances 2022-01-01 327
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 4
2021: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 310
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 189
Number of retired or separated participants receiving benefits 2021-01-01 50
Number of other retired or separated participants entitled to future benefits 2021-01-01 86
Total of all active and inactive participants 2021-01-01 325
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 325
Number of participants with account balances 2021-01-01 325
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 7
2020: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 291
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 195
Number of retired or separated participants receiving benefits 2020-01-01 36
Number of other retired or separated participants entitled to future benefits 2020-01-01 72
Total of all active and inactive participants 2020-01-01 303
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 303
Number of participants with account balances 2020-01-01 303
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 13
2009: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 174
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 167
Number of retired or separated participants receiving benefits 2009-01-01 0
Number of other retired or separated participants entitled to future benefits 2009-01-01 10
Total of all active and inactive participants 2009-01-01 177
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 177
Number of participants with account balances 2009-01-01 102
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2022: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	330
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	169
Number of retired or separated participants receiving benefits	2022-01-01	58
Number of other retired or separated participants entitled to future benefits	2022-01-01	100
Total of all active and inactive participants	2022-01-01	327
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	327
Number of participants with account balances	2022-01-01	327
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	4
2021: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	310
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	189
Number of retired or separated participants receiving benefits	2021-01-01	50
Number of other retired or separated participants entitled to future benefits	2021-01-01	86
Total of all active and inactive participants	2021-01-01	325
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	325
Number of participants with account balances	2021-01-01	325
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	7
2020: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	291
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	195
Number of retired or separated participants receiving benefits	2020-01-01	36
Number of other retired or separated participants entitled to future benefits	2020-01-01	72
Total of all active and inactive participants	2020-01-01	303
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	303
Number of participants with account balances	2020-01-01	303
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	13
2009: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	174
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	167
Number of retired or separated participants receiving benefits	2009-01-01	0
Number of other retired or separated participants entitled to future benefits	2009-01-01	10
Total of all active and inactive participants	2009-01-01	177
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	177
Number of participants with account balances	2009-01-01	102
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN

Measure	Date	Value
2022 : UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total transfer of assets to this plan	2022-12-31	$0
Total transfer of assets from this plan	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$-49,250
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$452,146
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$419,563
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$1,343,276
Value of total assets at end of year	2022-12-31	$9,505,068
Value of total assets at beginning of year	2022-12-31	$10,006,464
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$32,583
Total interest from all sources	2022-12-31	$3,744
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$500,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$686,956
Participant contributions at end of year	2022-12-31	$75,921
Participant contributions at beginning of year	2022-12-31	$117,836
Participant contributions at end of year	2022-12-31	$19,244
Participant contributions at beginning of year	2022-12-31	$12,822
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$100,630
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Income. Non cash contributions	2022-12-31	$0
Value of net income/loss	2022-12-31	$-501,396
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$9,505,068
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$10,006,464
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Investment advisory and management fees	2022-12-31	$32,583
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$8,927,615
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$9,361,417
Interest on participant loans	2022-12-31	$3,744
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-1,396,270
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$555,690
Employer contributions (assets) at end of year	2022-12-31	$482,288
Employer contributions (assets) at beginning of year	2022-12-31	$514,389
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$419,563
Did the plan have assets held for investment	2022-12-31	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	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	HENDERSON, HUTCHERSON & MCCULLOUGH
Accountancy firm EIN	2022-12-31	621114363
2021 : UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$2,299,395
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$1,177,356
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$1,170,995
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$1,081,529
Value of total assets at end of year	2021-12-31	$10,006,464
Value of total assets at beginning of year	2021-12-31	$8,884,425
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$6,361
Total interest from all sources	2021-12-31	$118,812
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$500,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$449,858
Participant contributions at end of year	2021-12-31	$117,836
Participant contributions at beginning of year	2021-12-31	$93,784
Participant contributions at end of year	2021-12-31	$12,822
Participant contributions at beginning of year	2021-12-31	$14,530
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$62,525
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$1,122,039
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$10,006,464
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$8,884,425
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Investment advisory and management fees	2021-12-31	$6,361
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$9,361,417
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$8,139,898
Value of interest in pooled separate accounts at beginning of year	2021-12-31	$6,755
Interest on participant loans	2021-12-31	$118,812
Net investment gain/loss from pooled separate accounts	2021-12-31	$1,099,054
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$569,146
Employer contributions (assets) at end of year	2021-12-31	$514,389
Employer contributions (assets) at beginning of year	2021-12-31	$629,458
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$1,170,995
Did the plan have assets held for investment	2021-12-31	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	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Unqualified
Accountancy firm name	2021-12-31	HENDERSON, HUTCHERSON & MCCULLOUGH
Accountancy firm EIN	2021-12-31	621114363
2020 : UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$192
Total income from all sources (including contributions)	2020-12-31	$2,430,561
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$682,462
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$631,138
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$1,201,870
Value of total assets at end of year	2020-12-31	$8,884,425
Value of total assets at beginning of year	2020-12-31	$7,136,518
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$51,324
Total interest from all sources	2020-12-31	$5,140
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$500,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$432,290
Participant contributions at end of year	2020-12-31	$93,784
Participant contributions at beginning of year	2020-12-31	$102,182
Participant contributions at end of year	2020-12-31	$14,530
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$82,882
Administrative expenses (other) incurred	2020-12-31	$45,120
Liabilities. Value of operating payables at beginning of year	2020-12-31	$192
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$1,748,099
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$8,884,425
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$7,136,326
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Investment advisory and management fees	2020-12-31	$6,204
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$8,139,898
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$6,563,614
Value of interest in pooled separate accounts at end of year	2020-12-31	$6,755
Value of interest in pooled separate accounts at beginning of year	2020-12-31	$5,677
Interest on participant loans	2020-12-31	$5,140
Net investment gain/loss from pooled separate accounts	2020-12-31	$1,223,551
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	Yes
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$686,698
Employer contributions (assets) at end of year	2020-12-31	$629,458
Employer contributions (assets) at beginning of year	2020-12-31	$465,045
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$631,138
Did the plan have assets held for investment	2020-12-31	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	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Unqualified
Accountancy firm name	2020-12-31	HENDERSON, HUTCHERSON & MCCULLOUGH
Accountancy firm EIN	2020-12-31	621114363

Form 5500 Responses for UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN

2022: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	No
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	No
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	Yes
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 – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2009: UNIVERSITY SURGICAL ASSOCIATES,PLLC 401-K PROFIT SHARING PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
2009-01-01	This submission is the final filing	No
2009-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-01-01	Plan is a collectively bargained plan	No
2009-01-01	Plan funding arrangement – Insurance	Yes
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-829478

Policy instance

Insurance contract or identification number	GA-829478
Number of Individuals Covered	0
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	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	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 $0
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	0
Insurance broker organization code?	3

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-829478

Policy instance

Insurance contract or identification number	GA-829478
Number of Individuals Covered	0
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $21,930
Total amount of fees paid to insurance company	USD $1
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	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 $21,930
Insurance broker organization code?	3
Amount paid for insurance broker fees	1
Additional information about fees paid to insurance broker	SALES AND ADMINISTRATION

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-829478

Policy instance

Insurance contract or identification number	GA-829478
Number of Individuals Covered	265
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $16,431
Total amount of fees paid to insurance company	USD $3,280
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	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 $16,431
Insurance broker organization code?	3
Amount paid for insurance broker fees	3280
Additional information about fees paid to insurance broker	SALES AND ADMINISTRATION

Potentially related plans

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Company Name:	UNIVERSITY SURGICAL ASSOCIATES, PLLC.
Employer identification number (EIN):	621658774
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)