401k Plan data: PINNACLE MEDICAL GROUP, INC. A PROFESSIONAL CORPORATION HEALTH & WELLNESS PLAN plan

PINNACLE MEDICAL GROUP, INC. A PROFESSIONAL CORPORATION HEALTH & WELLNESS PLAN 401k Plan overview

Plan Name	PINNACLE MEDICAL GROUP, INC. A PROFESSIONAL CORPORATION HEALTH & WELLNESS PLAN
Plan identification number	502

PINNACLE MEDICAL GROUP, INC. A PROFESSIONAL CORPORATION HEALTH & WELLNESS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Death benefits (include travel accident but not life insurance) 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

PINNACLE MEDICAL GROUP, INC. has sponsored the creation of one or more 401k plans.

Company Name: PINNACLE MEDICAL GROUP, INC.

Employer identification number (EIN): 770508373

NAIC Classification: 621498
NAIC Description: All Other Outpatient Care Centers

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PINNACLE MEDICAL GROUP, INC. A PROFESSIONAL CORPORATION HEALTH & WELLNESS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2017-12-01 SHELLEY MCGEE 2019-09-11

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2017-12-01	SHELLEY MCGEE	2019-09-11

Plan Statistics for PINNACLE MEDICAL GROUP, INC. A PROFESSIONAL CORPORATION HEALTH & WELLNESS PLAN

401k plan membership statisitcs for PINNACLE MEDICAL GROUP, INC. A PROFESSIONAL CORPORATION HEALTH & WELLNESS PLAN

Measure Date Value
2017: PINNACLE MEDICAL GROUP, INC. A PROFESSIONAL CORPORATION HEALTH & WELLNESS PLAN 2017 401k membership
Total participants, beginning-of-year 2017-12-01 102
Total number of active participants reported on line 7a of the Form 5500 2017-12-01 98
Number of retired or separated participants receiving benefits 2017-12-01 1
Number of other retired or separated participants entitled to future benefits 2017-12-01 0
Total of all active and inactive participants 2017-12-01 99
Number of employers contributing to the scheme 2017-12-01 0

Measure	Date	Value
2017: PINNACLE MEDICAL GROUP, INC. A PROFESSIONAL CORPORATION HEALTH & WELLNESS PLAN 2017 401k membership
Total participants, beginning-of-year	2017-12-01	102
Total number of active participants reported on line 7a of the Form 5500	2017-12-01	98
Number of retired or separated participants receiving benefits	2017-12-01	1
Number of other retired or separated participants entitled to future benefits	2017-12-01	0
Total of all active and inactive participants	2017-12-01	99
Number of employers contributing to the scheme	2017-12-01	0

Form 5500 Responses for PINNACLE MEDICAL GROUP, INC. A PROFESSIONAL CORPORATION HEALTH & WELLNESS PLAN

2017: PINNACLE MEDICAL GROUP, INC. A PROFESSIONAL CORPORATION HEALTH & WELLNESS PLAN 2017 form 5500 responses
2017-12-01	Type of plan entity	Single employer plan
2017-12-01	First time form 5500 has been submitted	Yes
2017-12-01	Plan funding arrangement – Insurance	Yes
2017-12-01	Plan funding arrangement – General assets of the sponsor	Yes
2017-12-01	Plan benefit arrangement – Insurance	Yes
2017-12-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

CIGNA HEALTH AND LIFE INSURANCE COMPANY AND AFFILIATES (National Association of Insurance Commissioners NAIC id number: 67369 )

Policy contract number

621015

Policy instance

Insurance contract or identification number	621015
Number of Individuals Covered	54
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $17,752
Total amount of fees paid to insurance company	USD $7,101
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $258,457
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

SGM608669

Policy instance

Insurance contract or identification number	SGM608669
Number of Individuals Covered	98
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $843
Total amount of fees paid to insurance company	USD $422
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 AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $8,430
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

S7445

Policy instance

Insurance contract or identification number	S7445
Number of Individuals Covered	35
Insurance policy start date	2017-12-01
Insurance policy end date	2018-11-30
Total amount of commissions paid to insurance broker	USD $12,198
Total amount of fees paid to insurance company	USD $828
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER,VOL. BENEFITS,VOL. BENEFITS
Welfare Benefit Premiums Paid to Carrier	USD $39,646
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	PINNACLE MEDICAL GROUP, INC.
Employer identification number (EIN):	770508373
NAIC Classification:	621498
NAIC Description:	All Other Outpatient Care Centers