401k Plan data: OLEAN MEDICAL PRACTICE, PLLC SECTION 125 FLEXIBLE BENEFIT PLAN plan

OLEAN MEDICAL PRACTICE, PLLC SECTION 125 FLEXIBLE BENEFIT PLAN 401k Plan overview

Plan Name	OLEAN MEDICAL PRACTICE, PLLC SECTION 125 FLEXIBLE BENEFIT PLAN
Plan identification number	501

OLEAN MEDICAL PRACTICE, PLLC SECTION 125 FLEXIBLE BENEFIT PLAN Benefits

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

401k Sponsoring company profile

OLEAN MEDICAL PRACTICE, PLLC has sponsored the creation of one or more 401k plans.

Company Name: OLEAN MEDICAL PRACTICE, PLLC

Employer identification number (EIN): 881324896

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan OLEAN MEDICAL PRACTICE, PLLC SECTION 125 FLEXIBLE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01

Plan Statistics for OLEAN MEDICAL PRACTICE, PLLC SECTION 125 FLEXIBLE BENEFIT PLAN

401k plan membership statisitcs for OLEAN MEDICAL PRACTICE, PLLC SECTION 125 FLEXIBLE BENEFIT PLAN

Measure Date Value
2022: OLEAN MEDICAL PRACTICE, PLLC SECTION 125 FLEXIBLE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 197
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 186
Total of all active and inactive participants 2022-01-01 186

Measure	Date	Value
2022: OLEAN MEDICAL PRACTICE, PLLC SECTION 125 FLEXIBLE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	197
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	186
Total of all active and inactive participants	2022-01-01	186

Form 5500 Responses for OLEAN MEDICAL PRACTICE, PLLC SECTION 125 FLEXIBLE BENEFIT PLAN

2022: OLEAN MEDICAL PRACTICE, PLLC SECTION 125 FLEXIBLE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

00388865

Policy instance

Insurance contract or identification number	00388865
Number of Individuals Covered	121
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,588
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $44,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,282
Insurance broker organization code?	3

HEALTHNOW NEW YORK, INC. DBA BLUESHIELD OF NORTHEASTERN NEW YORK (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

00043832

Policy instance

Insurance contract or identification number	00043832
Number of Individuals Covered	113
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $33,627
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $22,709
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

42370

Policy instance

Insurance contract or identification number	42370
Number of Individuals Covered	12
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $27
Total amount of fees paid to insurance company	USD $11
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH & DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $2,241
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27
Amount paid for insurance broker fees	11
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

FIRST UNUM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 64297 )

Policy contract number

42429

Policy instance

Insurance contract or identification number	42429
Number of Individuals Covered	15
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $495
Total amount of fees paid to insurance company	USD $41
Long Term Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,099
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $495
Amount paid for insurance broker fees	41
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

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

Policy contract number

52-0807803

Policy instance

Insurance contract or identification number	52-0807803
Number of Individuals Covered	29
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $4,161
Total amount of fees paid to insurance company	USD $37
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $24,807
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,483
Amount paid for insurance broker fees	25
Insurance broker organization code?	3

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Company Name:	OLEAN MEDICAL PRACTICE, PLLC
Employer identification number (EIN):	881324896
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)