401k Plan data: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN plan

BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 401k Plan overview

Plan Name	BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN
Plan identification number	001

BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
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.
Participant-directed brokerage accounts provided as an investment option under the plan.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Plan covering Self-Employed individuals.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

BEND UROLOGY ASSOCIATES LLC has sponsored the creation of one or more 401k plans.

Company Name: BEND UROLOGY ASSOCIATES LLC

Employer identification number (EIN): 930964320

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

Additional information about BEND UROLOGY ASSOCIATES LLC

Jurisdiction of Incorporation: Oregon Secretary of State Corporations Division

Incorporation Date: 1996-12-18

Company Identification Number: 54873287

Legal Registered Office Address: KARNOPP PETERSEN LLP

BEND
United States of America (USA)
97702

More information about BEND UROLOGY ASSOCIATES LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2021-01-01
001 2020-01-01 NORA V TAKLA 2021-04-21
001 2019-01-01 NORA V TAKLA 2020-08-31
001 2018-01-01
001 2017-01-01
001 2017-01-01 NORA V TAKLA 2019-07-15
001 2016-01-01
001 2015-01-01
001 2014-01-01 BRIAN O'HOLLAREN 2015-04-23
001 2013-01-01 BRIAN O'HOLLAREN 2014-06-27
001 2012-01-01 BRIAN O'HOLLAREN 2013-06-04
001 2011-01-01 NORA TAKLA 2012-04-23
001 2010-01-01 MICHEL A. BOILEAU, M.D. 2011-08-15

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2021-01-01
001	2020-01-01	NORA V TAKLA	2021-04-21
001	2019-01-01	NORA V TAKLA	2020-08-31
001	2018-01-01
001	2017-01-01
001	2017-01-01	NORA V TAKLA	2019-07-15
001	2016-01-01
001	2015-01-01
001	2014-01-01	BRIAN O'HOLLAREN	2015-04-23
001	2013-01-01	BRIAN O'HOLLAREN	2014-06-27
001	2012-01-01	BRIAN O'HOLLAREN	2013-06-04
001	2011-01-01	NORA TAKLA	2012-04-23
001	2010-01-01	MICHEL A. BOILEAU, M.D.	2011-08-15

Plan Statistics for BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN

401k plan membership statisitcs for BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN

Measure Date Value
2020: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 18
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 0
Number of retired or separated participants receiving benefits 2020-01-01 1
Number of other retired or separated participants entitled to future benefits 2020-01-01 2
Total of all active and inactive participants 2020-01-01 3
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 3
Number of participants with account balances 2020-01-01 3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 33
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 5
Number of retired or separated participants receiving benefits 2019-01-01 1
Number of other retired or separated participants entitled to future benefits 2019-01-01 12
Total of all active and inactive participants 2019-01-01 18
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 18
Number of participants with account balances 2019-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 8
2018: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 42
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 21
Number of retired or separated participants receiving benefits 2018-01-01 1
Number of other retired or separated participants entitled to future benefits 2018-01-01 11
Total of all active and inactive participants 2018-01-01 33
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 33
Number of participants with account balances 2018-01-01 33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 0
2017: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 46
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 20
Number of retired or separated participants receiving benefits 2017-01-01 4
Number of other retired or separated participants entitled to future benefits 2017-01-01 18
Total of all active and inactive participants 2017-01-01 42
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 42
Number of participants with account balances 2017-01-01 42
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 9
2016: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 38
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 28
Number of retired or separated participants receiving benefits 2016-01-01 4
Number of other retired or separated participants entitled to future benefits 2016-01-01 14
Total of all active and inactive participants 2016-01-01 46
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 46
Number of participants with account balances 2016-01-01 46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 8

Measure	Date	Value
2020: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	18
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	0
Number of retired or separated participants receiving benefits	2020-01-01	1
Number of other retired or separated participants entitled to future benefits	2020-01-01	2
Total of all active and inactive participants	2020-01-01	3
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	3
Number of participants with account balances	2020-01-01	3
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	33
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	5
Number of retired or separated participants receiving benefits	2019-01-01	1
Number of other retired or separated participants entitled to future benefits	2019-01-01	12
Total of all active and inactive participants	2019-01-01	18
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	18
Number of participants with account balances	2019-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	8
2018: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	42
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	21
Number of retired or separated participants receiving benefits	2018-01-01	1
Number of other retired or separated participants entitled to future benefits	2018-01-01	11
Total of all active and inactive participants	2018-01-01	33
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	33
Number of participants with account balances	2018-01-01	33
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	0
2017: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	46
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	20
Number of retired or separated participants receiving benefits	2017-01-01	4
Number of other retired or separated participants entitled to future benefits	2017-01-01	18
Total of all active and inactive participants	2017-01-01	42
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	42
Number of participants with account balances	2017-01-01	42
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	9
2016: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	38
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	28
Number of retired or separated participants receiving benefits	2016-01-01	4
Number of other retired or separated participants entitled to future benefits	2016-01-01	14
Total of all active and inactive participants	2016-01-01	46
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	46
Number of participants with account balances	2016-01-01	46
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	8

Financial Data on BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN

Measure	Date	Value
2020 : BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2020 401k financial data
Total plan liabilities at end of year	2020-12-31	$1
Total plan liabilities at beginning of year	2020-12-31	$2,550
Total income from all sources	2020-12-31	$117,000
Expenses. Total of all expenses incurred	2020-12-31	$2,423,136
Benefits paid (including direct rollovers)	2020-12-31	$2,402,837
Total plan assets at end of year	2020-12-31	$24,656
Total plan assets at beginning of year	2020-12-31	$2,333,341
Value of fidelity bond covering the plan	2020-12-31	$366,000
Expenses. Other expenses not covered elsewhere	2020-12-31	$81
Other income received	2020-12-31	$117,000
Net income (gross income less expenses)	2020-12-31	$-2,306,136
Net plan assets at end of year (total assets less liabilities)	2020-12-31	$24,655
Net plan assets at beginning of year (total assets less liabilities)	2020-12-31	$2,330,791
Assets. Value of real-estate (other than employer real property)	2020-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2020-12-31	$20,218
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2020-12-31	$356,130
2019 : BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2019 401k financial data
Total plan liabilities at end of year	2019-12-31	$2,550
Total plan liabilities at beginning of year	2019-12-31	$7,571
Total income from all sources	2019-12-31	$519,484
Expenses. Total of all expenses incurred	2019-12-31	$1,847,211
Benefits paid (including direct rollovers)	2019-12-31	$1,805,945
Total plan assets at end of year	2019-12-31	$2,333,341
Total plan assets at beginning of year	2019-12-31	$3,666,089
Value of fidelity bond covering the plan	2019-12-31	$366,000
Expenses. Other expenses not covered elsewhere	2019-12-31	$12
Other income received	2019-12-31	$519,484
Net income (gross income less expenses)	2019-12-31	$-1,327,727
Net plan assets at end of year (total assets less liabilities)	2019-12-31	$2,330,791
Net plan assets at beginning of year (total assets less liabilities)	2019-12-31	$3,658,518
Assets. Value of real-estate (other than employer real property)	2019-12-31	$356,130
Expenses. Administrative service providers (salaries,fees and commissions)	2019-12-31	$41,254
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
2018 : BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2018 401k financial data
Total plan liabilities at end of year	2018-12-31	$7,571
Total plan liabilities at beginning of year	2018-12-31	$11
Total income from all sources	2018-12-31	$12,304
Expenses. Total of all expenses incurred	2018-12-31	$486,080
Benefits paid (including direct rollovers)	2018-12-31	$447,677
Total plan assets at end of year	2018-12-31	$3,666,089
Total plan assets at beginning of year	2018-12-31	$4,132,305
Value of fidelity bond covering the plan	2018-12-31	$414,000
Total contributions received or receivable from participants	2018-12-31	$77,862
Expenses. Other expenses not covered elsewhere	2018-12-31	$7,909
Other income received	2018-12-31	$-148,407
Net income (gross income less expenses)	2018-12-31	$-473,776
Net plan assets at end of year (total assets less liabilities)	2018-12-31	$3,658,518
Net plan assets at beginning of year (total assets less liabilities)	2018-12-31	$4,132,294
Assets. Value of real-estate (other than employer real property)	2018-12-31	$335,310
Total contributions received or receivable from employer(s)	2018-12-31	$82,849
Expenses. Administrative service providers (salaries,fees and commissions)	2018-12-31	$30,494
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
2017 : BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2017 401k financial data
Total plan liabilities at end of year	2017-12-31	$11
Total plan liabilities at beginning of year	2017-12-31	$50
Total income from all sources	2017-12-31	$704,087
Expenses. Total of all expenses incurred	2017-12-31	$66,591
Benefits paid (including direct rollovers)	2017-12-31	$30,880
Total plan assets at end of year	2017-12-31	$4,132,705
Total plan assets at beginning of year	2017-12-31	$3,495,248
Value of fidelity bond covering the plan	2017-12-31	$330,000
Total contributions received or receivable from participants	2017-12-31	$85,252
Expenses. Other expenses not covered elsewhere	2017-12-31	$1,209
Other income received	2017-12-31	$495,655
Net income (gross income less expenses)	2017-12-31	$637,496
Net plan assets at end of year (total assets less liabilities)	2017-12-31	$4,132,694
Net plan assets at beginning of year (total assets less liabilities)	2017-12-31	$3,495,198
Assets. Value of real-estate (other than employer real property)	2017-12-31	$360,000
Total contributions received or receivable from employer(s)	2017-12-31	$123,180
Expenses. Administrative service providers (salaries,fees and commissions)	2017-12-31	$34,502
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
2016 : BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2016 401k financial data
Total plan liabilities at end of year	2016-12-31	$50
Total income from all sources	2016-12-31	$500,995
Expenses. Total of all expenses incurred	2016-12-31	$330,198
Benefits paid (including direct rollovers)	2016-12-31	$298,981
Total plan assets at end of year	2016-12-31	$3,495,248
Total plan assets at beginning of year	2016-12-31	$3,324,401
Value of fidelity bond covering the plan	2016-12-31	$330,000
Total contributions received or receivable from participants	2016-12-31	$112,738
Expenses. Other expenses not covered elsewhere	2016-12-31	$884
Other income received	2016-12-31	$234,898
Net income (gross income less expenses)	2016-12-31	$170,797
Net plan assets at end of year (total assets less liabilities)	2016-12-31	$3,495,198
Net plan assets at beginning of year (total assets less liabilities)	2016-12-31	$3,324,401
Assets. Value of real-estate (other than employer real property)	2016-12-31	$292,860
Total contributions received or receivable from employer(s)	2016-12-31	$153,359
Expenses. Administrative service providers (salaries,fees and commissions)	2016-12-31	$30,333
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0

Form 5500 Responses for BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN

2020: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes
2017: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: BEND UROLOGY ASSOCIATES, L.L.C. 401K PROFIT SHARING 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 funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

801548-000

Policy instance

Insurance contract or identification number	801548-000
Number of Individuals Covered	18
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $1,722
Total amount of fees paid to insurance company	USD $172
Are there contracts with allocated funds for individual policies?	0
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?	Yes
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
Commission paid to Insurance Broker	USD $1,722
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

801548-000

Policy instance

Insurance contract or identification number	801548-000
Number of Individuals Covered	29
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $3,255
Total amount of fees paid to insurance company	USD $324
Are there contracts with allocated funds for individual policies?	0
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?	Yes
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
Commission paid to Insurance Broker	USD $3,255
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3

TRANSAMERICA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 86231 )

Policy contract number

801548-000

Policy instance

Insurance contract or identification number	801548-000
Number of Individuals Covered	42
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $3,332
Total amount of fees paid to insurance company	USD $336
Are there contracts with allocated funds for individual policies?	0
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?	Yes
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
Commission paid to Insurance Broker	USD $3,332
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	BROKER FEES
Insurance broker organization code?	3
Insurance broker name	NORTHWEST RETIREMENT PLANS

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Company Name:	BEND UROLOGY ASSOCIATES LLC
Employer identification number (EIN):	930964320
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)

Jurisdiction of Incorporation:	Oregon Secretary of State Corporations Division
Incorporation Date:	1996-12-18
Company Identification Number:	54873287
Legal Registered Office Address:	KARNOPP PETERSEN LLP BEND United States of America (USA) 97702