401k Plan data: PAIN DOCTOR MANAGEMENT COMPANY LLC MEDICAL BENEFIT PLAN plan

PAIN DOCTOR MANAGEMENT COMPANY LLC MEDICAL BENEFIT PLAN 401k Plan overview

Plan Name	PAIN DOCTOR MANAGEMENT COMPANY LLC MEDICAL BENEFIT PLAN
Plan identification number	502

PAIN DOCTOR MANAGEMENT COMPANY LLC MEDICAL BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision Other welfare benefit cover 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

US PAIN SPECIALISTS has sponsored the creation of one or more 401k plans.

Company Name: US PAIN SPECIALISTS

Employer identification number (EIN): 832248033

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PAIN DOCTOR MANAGEMENT COMPANY LLC MEDICAL BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2019-01-01 VERONICA LUGO 2020-07-28

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
502	2019-01-01	VERONICA LUGO	2020-07-28

Plan Statistics for PAIN DOCTOR MANAGEMENT COMPANY LLC MEDICAL BENEFIT PLAN

401k plan membership statisitcs for PAIN DOCTOR MANAGEMENT COMPANY LLC MEDICAL BENEFIT PLAN

Measure Date Value
2019: PAIN DOCTOR MANAGEMENT COMPANY LLC MEDICAL BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 236
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 67
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 67
Number of employers contributing to the scheme 2019-01-01 0

Measure	Date	Value
2019: PAIN DOCTOR MANAGEMENT COMPANY LLC MEDICAL BENEFIT PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	236
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	67
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	67
Number of employers contributing to the scheme	2019-01-01	0

Form 5500 Responses for PAIN DOCTOR MANAGEMENT COMPANY LLC MEDICAL BENEFIT PLAN

2019: PAIN DOCTOR MANAGEMENT COMPANY LLC MEDICAL BENEFIT PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	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

3342451

Policy instance

Insurance contract or identification number	3342451
Number of Individuals Covered	67
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $5,004
Total amount of fees paid to insurance company	USD $19,626
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $705,027
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,004
Amount paid for insurance broker fees	19626
Additional information about fees paid to insurance broker	BENEFIT ADVISOR PAYMENTS
Insurance broker organization code?	3

Potentially related plans

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Company Name:	US PAIN SPECIALISTS
Employer identification number (EIN):	832248033
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)