401k Plan data: CIRCUS DOG PRODUCTIONS, INC. plan

CIRCUS DOG PRODUCTIONS, INC. 401k Plan overview

Plan Name	CIRCUS DOG PRODUCTIONS, INC.
Plan identification number	501

CIRCUS DOG PRODUCTIONS, INC. Benefits

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

CALIFORNIA PHYSICIANS SERVICE DBA BLUE SHIELD OF CALIFORNIA has sponsored the creation of one or more 401k plans.

Company Name: CALIFORNIA PHYSICIANS SERVICE DBA BLUE SHIELD OF CALIFORNIA

Employer identification number (EIN): 940360524

NAIC Classification: 524140

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CIRCUS DOG PRODUCTIONS, INC.

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-03-01 BRYAN BACH
501 2015-03-01 BRYAN BACH

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2016-03-01	BRYAN BACH
501	2015-03-01	BRYAN BACH

Plan Statistics for CIRCUS DOG PRODUCTIONS, INC.

401k plan membership statisitcs for CIRCUS DOG PRODUCTIONS, INC.

Measure Date Value
2016: CIRCUS DOG PRODUCTIONS, INC. 2016 401k membership
Total participants, beginning-of-year 2016-03-01 123
Total number of active participants reported on line 7a of the Form 5500 2016-03-01 123
Number of retired or separated participants receiving benefits 2016-03-01 0
Number of other retired or separated participants entitled to future benefits 2016-03-01 0
Total of all active and inactive participants 2016-03-01 123
2015: CIRCUS DOG PRODUCTIONS, INC. 2015 401k membership
Total participants, beginning-of-year 2015-03-01 100
Total number of active participants reported on line 7a of the Form 5500 2015-03-01 123
Number of retired or separated participants receiving benefits 2015-03-01 0
Number of other retired or separated participants entitled to future benefits 2015-03-01 0
Total of all active and inactive participants 2015-03-01 123

Measure	Date	Value
2016: CIRCUS DOG PRODUCTIONS, INC. 2016 401k membership
Total participants, beginning-of-year	2016-03-01	123
Total number of active participants reported on line 7a of the Form 5500	2016-03-01	123
Number of retired or separated participants receiving benefits	2016-03-01	0
Number of other retired or separated participants entitled to future benefits	2016-03-01	0
Total of all active and inactive participants	2016-03-01	123
2015: CIRCUS DOG PRODUCTIONS, INC. 2015 401k membership
Total participants, beginning-of-year	2015-03-01	100
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	123
Number of retired or separated participants receiving benefits	2015-03-01	0
Number of other retired or separated participants entitled to future benefits	2015-03-01	0
Total of all active and inactive participants	2015-03-01	123

Form 5500 Responses for CIRCUS DOG PRODUCTIONS, INC.

2016: CIRCUS DOG PRODUCTIONS, INC. 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	Submission has been amended	No
2016-03-01	This submission is the final filing	No
2016-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-03-01	Plan is a collectively bargained plan	No
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes
2015: CIRCUS DOG PRODUCTIONS, INC. 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Submission has been amended	No
2015-03-01	This submission is the final filing	No
2015-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-03-01	Plan is a collectively bargained plan	No
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

CALIFORNIA PHYSICIANS SERVICE (National Association of Insurance Commissioners NAIC id number: 47732 )

Policy contract number

W0051267

Policy instance

Insurance contract or identification number	W0051267
Number of Individuals Covered	149
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $35,897
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $717,948
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $35,897
Insurance broker organization code?	3
Insurance broker name	POMS AND ASSOCIATES INS. BROKERS

HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )

Policy contract number

681430

Policy instance

Insurance contract or identification number	681430
Number of Individuals Covered	55
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $3,885
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $48,908
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,885
Insurance broker organization code?	3
Insurance broker name	POMS AND ASSOCIATES INS. BROKERS

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

12279649

Policy instance

Insurance contract or identification number	12279649
Number of Individuals Covered	68
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $909
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
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	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $13,882
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $909
Insurance broker organization code?	3
Insurance broker name	POMS AND ASSOCIATES INS. BROKERS

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Company Name:	CALIFORNIA PHYSICIANS SERVICE DBA BLUE SHIELD OF CALIFORNIA
Employer identification number (EIN):	940360524
NAIC Classification:	524140