401k Plan data: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN plan

SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 401k Plan overview

Plan Name	SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN
Plan identification number	506

SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Temporary disability (accident and sickness) 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. Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

SOUTHLAKE CLINIC, INC. P.S. has sponsored the creation of one or more 401k plans.

Company Name: SOUTHLAKE CLINIC, INC. P.S.

Employer identification number (EIN): 910870154

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

Additional information about SOUTHLAKE CLINIC, INC. P.S.

Jurisdiction of Incorporation: Washington Secretary of State Corporations Division

Incorporation Date: 1971-10-06

Company Identification Number: 600052154

Legal Registered Office Address: 4011 TALBOT RD S STE 500

RENTON
United States of America (USA)
980550000

More information about SOUTHLAKE CLINIC, INC. P.S.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
506 2017-01-01
506 2016-01-01 JAMES HUDSON
506 2015-01-01 LAURA COWAN
506 2014-01-01 DONALD ROBERTSON
506 2013-01-01 DONALD ROBERTSON
506 2012-01-01 DONALD ROBERTSON
506 2011-01-01 DONALD ROBERTSON
506 2009-01-01 DON ROBERTSON DON ROBERTSON 2010-07-19
506 2009-01-01

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
506	2017-01-01
506	2016-01-01	JAMES HUDSON
506	2015-01-01	LAURA COWAN
506	2014-01-01	DONALD ROBERTSON
506	2013-01-01	DONALD ROBERTSON
506	2012-01-01	DONALD ROBERTSON
506	2011-01-01	DONALD ROBERTSON
506	2009-01-01	DON ROBERTSON	DON ROBERTSON	2010-07-19
506	2009-01-01

Plan Statistics for SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN

401k plan membership statisitcs for SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN

Measure Date Value
2017: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 97
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 0
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 0
Total of all active and inactive participants 2017-01-01 0
2016: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 107
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 97
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 0
Total of all active and inactive participants 2016-01-01 97
2015: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 107
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 107
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 0
Total of all active and inactive participants 2015-01-01 107
2014: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 107
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 0
Total of all active and inactive participants 2014-01-01 107
2013: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 98
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 0
Total of all active and inactive participants 2013-01-01 98
2012: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 108
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 101
Number of retired or separated participants receiving benefits 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 2012-01-01 101
2011: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 130
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 106
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 0
Total of all active and inactive participants 2011-01-01 106
2009: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 128
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 131
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 0
Total of all active and inactive participants 2009-01-01 131

Measure	Date	Value
2017: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	97
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	0
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	0
Total of all active and inactive participants	2017-01-01	0
2016: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	107
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	97
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	0
Total of all active and inactive participants	2016-01-01	97
2015: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	107
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	107
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	0
Total of all active and inactive participants	2015-01-01	107
2014: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	107
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	0
Total of all active and inactive participants	2014-01-01	107
2013: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	98
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	0
Total of all active and inactive participants	2013-01-01	98
2012: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	108
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	101
Number of retired or separated participants receiving benefits	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	101
2011: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	130
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	106
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	0
Total of all active and inactive participants	2011-01-01	106
2009: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	128
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	131
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	0
Total of all active and inactive participants	2009-01-01	131

Form 5500 Responses for SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN

2017: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	This submission is the final filing	Yes
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2015: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2014: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2009: SOUTHLAKE CLINIC, INC. PS VOLUNTARY SHORT TERM DISABILITY PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	Yes
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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	STD239619
Policy instance	1
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	STD239619
Policy instance	1
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	767269G
Policy instance	1
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	767269G
Policy instance	1
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	767269G
Policy instance	1
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	767269G
Policy instance	1
UNION SECURITY INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70408 )
Policy contract number	5320506
Policy instance	1
HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )
Policy contract number	767269G
Policy instance	2

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Company Name:	SOUTHLAKE CLINIC, INC. P.S.
Employer identification number (EIN):	910870154
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)

Jurisdiction of Incorporation:	Washington Secretary of State Corporations Division
Incorporation Date:	1971-10-06
Company Identification Number:	600052154
Legal Registered Office Address:	4011 TALBOT RD S STE 500 RENTON United States of America (USA) 980550000