401k Plan data: STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN plan

STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 401k Plan overview

Plan Name	STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN
Plan identification number	001

STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

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.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

STILLWATER MEDICAL GROUP has sponsored the creation of one or more 401k plans.

Company Name: STILLWATER MEDICAL GROUP

Employer identification number (EIN): 830379473

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2012-01-01 DOUG JOHNSON 2013-10-07 DOUG JOHNSON 2013-10-07
001 2011-01-01 DOUG JOHNSON 2012-10-15 DOUG JOHNSON 2012-10-15
001 2009-01-01 DOUGLAS JOHNSON

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
001	2012-01-01	DOUG JOHNSON	2013-10-07	DOUG JOHNSON	2013-10-07
001	2011-01-01	DOUG JOHNSON	2012-10-15	DOUG JOHNSON	2012-10-15
001	2009-01-01	DOUGLAS JOHNSON

Plan Statistics for STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN

401k plan membership statisitcs for STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN

Measure Date Value
2012: STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 481
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 0
Number of other retired or separated participants entitled to future benefits 2012-01-01 0
Total of all active and inactive participants 2012-01-01 0
Total participants 2012-01-01 0
Number of participants with account balances 2012-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 0
2011: STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 439
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 411
Number of retired or separated participants receiving benefits 2011-01-01 0
Number of other retired or separated participants entitled to future benefits 2011-01-01 70
Total of all active and inactive participants 2011-01-01 481
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 481
Number of participants with account balances 2011-01-01 438
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 21
2009: STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 417
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 343
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 45
Total of all active and inactive participants 2009-01-01 388
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 388
Number of participants with account balances 2009-01-01 388
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 16

Measure	Date	Value
2012: STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	481
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	0
Number of other retired or separated participants entitled to future benefits	2012-01-01	0
Total of all active and inactive participants	2012-01-01	0
Total participants	2012-01-01	0
Number of participants with account balances	2012-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	0
2011: STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	439
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	411
Number of retired or separated participants receiving benefits	2011-01-01	0
Number of other retired or separated participants entitled to future benefits	2011-01-01	70
Total of all active and inactive participants	2011-01-01	481
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	481
Number of participants with account balances	2011-01-01	438
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	21
2009: STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	417
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	343
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	45
Total of all active and inactive participants	2009-01-01	388
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	388
Number of participants with account balances	2009-01-01	388
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	16

Financial Data on STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN

Measure	Date	Value
2012 : STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2012 401k financial data
Total transfer of assets from this plan	2012-12-31	$42,382,768
Total income from all sources (including contributions)	2012-12-31	$3,925,577
Total of all expenses incurred	2012-12-31	$2,648,961
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$2,636,449
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$645,398
Value of total assets at end of year	2012-12-31	$0
Value of total assets at beginning of year	2012-12-31	$41,106,152
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$12,512
Total interest from all sources	2012-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$3,280,179
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2012-12-31	$3,280,179
Administrative expenses professional fees incurred	2012-12-31	$12,512
Was this plan covered by a fidelity bond	2012-12-31	No
If this is an individual account plan, was there a blackout period	2012-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$575,261
Total non interest bearing cash at end of year	2012-12-31	$0
Total non interest bearing cash at beginning of year	2012-12-31	$177,282
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$1,276,616
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$0
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$41,106,152
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2012-12-31	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2012-12-31	$35,788,609
Interest earned on other investments	2012-12-31	$0
Value of interest in common/collective trusts at end of year	2012-12-31	$0
Value of interest in common/collective trusts at beginning of year	2012-12-31	$4,097,279
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2012-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2012-12-31	$367,448
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2012-12-31	$0
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$70,137
Employer contributions (assets) at end of year	2012-12-31	$0
Employer contributions (assets) at beginning of year	2012-12-31	$675,534
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$2,636,449
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2012-12-31	No
Did the plan have assets held for investment	2012-12-31	No
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	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	No
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	KPMG, LLP
Accountancy firm EIN	2012-12-31	135665207
2011 : STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2011 401k financial data
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$35,031
Total income from all sources (including contributions)	2011-12-31	$2,341,376
Total of all expenses incurred	2011-12-31	$6,193,766
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$6,148,775
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$2,875,785
Value of total assets at end of year	2011-12-31	$41,106,152
Value of total assets at beginning of year	2011-12-31	$44,993,573
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$44,991
Total interest from all sources	2011-12-31	$30,392
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$789,530
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2011-12-31	$789,530
Administrative expenses professional fees incurred	2011-12-31	$33,411
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$15,000,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$1,808,580
Participant contributions at end of year	2011-12-31	$0
Participant contributions at beginning of year	2011-12-31	$1,000
Income. Received or receivable in cash from other sources (including rollovers)	2011-12-31	$0
Administrative expenses (other) incurred	2011-12-31	$11,580
Total non interest bearing cash at end of year	2011-12-31	$177,282
Total non interest bearing cash at beginning of year	2011-12-31	$50
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$-3,852,390
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$41,106,152
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$44,958,542
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2011-12-31	$35,788,609
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2011-12-31	$38,608,751
Interest earned on other investments	2011-12-31	$30,392
Value of interest in common/collective trusts at end of year	2011-12-31	$4,097,279
Value of interest in common/collective trusts at beginning of year	2011-12-31	$5,378,254
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$367,448
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$337,056
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2011-12-31	$-1,354,331
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	No
Was there a failure to transmit to the plan any participant contributions	2011-12-31	No
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Contributions received in cash from employer	2011-12-31	$1,067,205
Employer contributions (assets) at end of year	2011-12-31	$675,534
Employer contributions (assets) at beginning of year	2011-12-31	$668,462
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$6,148,775
Liabilities. Value of benefit claims payable at end of year	2011-12-31	$0
Liabilities. Value of benefit claims payable at beginning of year	2011-12-31	$35,031
Did the plan have assets held for investment	2011-12-31	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	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	KPMG LLP
Accountancy firm EIN	2011-12-31	135665207
2010 : STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2010 401k financial data
Total unrealized appreciation/depreciation of assets	2010-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$35,031
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$50,602
Total income from all sources (including contributions)	2010-12-31	$7,190,710
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$4,602,182
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$4,560,280
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$2,504,479
Value of total assets at end of year	2010-12-31	$44,993,573
Value of total assets at beginning of year	2010-12-31	$42,420,616
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$41,902
Total interest from all sources	2010-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$881,029
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2010-12-31	$881,029
Administrative expenses professional fees incurred	2010-12-31	$26,628
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$500,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$1,690,455
Participant contributions at end of year	2010-12-31	$1,000
Income. Received or receivable in cash from other sources (including rollovers)	2010-12-31	$29,108
Other income not declared elsewhere	2010-12-31	$27,556
Administrative expenses (other) incurred	2010-12-31	$15,274
Total non interest bearing cash at end of year	2010-12-31	$50
Total non interest bearing cash at beginning of year	2010-12-31	$64,564
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$2,588,528
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$44,958,542
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$42,370,014
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2010-12-31	$38,608,751
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2010-12-31	$36,038,079
Value of interest in common/collective trusts at end of year	2010-12-31	$5,378,254
Value of interest in common/collective trusts at beginning of year	2010-12-31	$5,320,078
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$337,056
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$397,895
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2010-12-31	$3,622,143
Net investment gain or loss from common/collective trusts	2010-12-31	$155,503
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$784,916
Employer contributions (assets) at end of year	2010-12-31	$668,462
Employer contributions (assets) at beginning of year	2010-12-31	$600,000
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$4,560,280
Liabilities. Value of benefit claims payable at end of year	2010-12-31	$35,031
Liabilities. Value of benefit claims payable at beginning of year	2010-12-31	$50,602
Did the plan have assets held for investment	2010-12-31	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	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	LARSON ALLEN LLP
Accountancy firm EIN	2010-12-31	410746749
2009 : STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN

2012: STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	This submission is the final filing	Yes
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: STILLWATER MEDICAL GROUP RETIREMENT SAVINGS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2009: STILLWATER MEDICAL GROUP RETIREMENT SAVINGS 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 - Trust	Yes

Insurance Providers Used on plan

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

42684

Policy instance

Insurance contract or identification number	42684
Number of Individuals Covered	0
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
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?	Yes
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN EQUITY INVESTMENT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61689 )

Policy contract number

VARIOUS

Policy instance

Insurance contract or identification number	VARIOUS
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
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?	Yes
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STATE FARM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69108 )

Policy contract number

VARIOUS

Policy instance

Insurance contract or identification number	VARIOUS
Number of Individuals Covered	0
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
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?	Yes
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

42684

Policy instance

Insurance contract or identification number	42684
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
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?	Yes
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN EQUITY INVESTMENT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61689 )

Policy contract number

VARIOUS

Policy instance

Insurance contract or identification number	VARIOUS
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
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?	Yes
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STATE FARM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69108 )

Policy contract number

VARIOUS

Policy instance

Insurance contract or identification number	VARIOUS
Number of Individuals Covered	1
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
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?	Yes
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

NORTHWESTERN MUTUAL (National Association of Insurance Commissioners NAIC id number: 67091 )

Policy contract number

42684

Policy instance

Insurance contract or identification number	42684
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
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?	Yes
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

STATE FARM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69108 )

Policy contract number

VARIOUS

Policy instance

Insurance contract or identification number	VARIOUS
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
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?	Yes
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

AMERICAN EQUITY INVESTMENT LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61689 )

Policy contract number

VARIOUS

Policy instance

Insurance contract or identification number	VARIOUS
Number of Individuals Covered	2
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
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?	Yes
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

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Company Name:	STILLWATER MEDICAL GROUP
Employer identification number (EIN):	830379473
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)