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| Plan Name | FELIPE DOMINGUEZ, MD, PA WELFARE BENEFIT PLAN |
| Plan identification number | 501 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | FELIPE DOMINGUEZ, MD, PA |
| Employer identification number (EIN): | 061832634 |
| NAIC Classification: | 621111 |
| NAIC Description: | Offices of Physicians (except Mental Health Specialists) |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 501 | 2020-11-01 | JESSICA SABA | 2022-08-28 | ||
| 501 | 2019-11-01 | JESSICA SABA | 2021-07-02 | ||
| 501 | 2018-11-01 | JESSICA HOMAN | 2020-07-29 | ||
| 501 | 2017-11-01 | FELIPE DOMINGUEZ | 2019-05-14 | ||
| 501 | 2016-11-01 | ||||
| 501 | 2015-11-01 | ||||
| 501 | 2014-11-01 | FELIPE DOMINGUEZ | 2016-03-03 | ||
| 501 | 2013-11-01 | FELIPE DOMINGUEZ | 2015-03-06 | ||
| 501 | 2012-11-01 | FELIPE DOMINGUEZ | 2014-01-31 | ||
| 501 | 2011-11-01 | FELIPE DOMINGUEZ |
| Measure | Date | Value |
|---|---|---|
| 2011: FELIPE DOMINGUEZ, MD, PA WELFARE BENEFIT PLAN 2011 401k membership | ||
| Total participants, beginning-of-year | 2011-11-01 | 1 |
| Total number of active participants reported on line 7a of the Form 5500 | 2011-11-01 | 1 |
| Number of retired or separated participants receiving benefits | 2011-11-01 | 0 |
| Number of other retired or separated participants entitled to future benefits | 2011-11-01 | 0 |
| Total of all active and inactive participants | 2011-11-01 | 1 |
| Measure | Date | Value |
|---|---|---|
| 2012 : FELIPE DOMINGUEZ, MD, PA WELFARE BENEFIT PLAN 2012 401k financial data | ||
| Total plan liabilities at end of year | 2012-10-31 | $191,680 |
| Total plan liabilities at beginning of year | 2012-10-31 | $146,356 |
| Total income from all sources | 2012-10-31 | $50,000 |
| Expenses. Total of all expenses incurred | 2012-10-31 | $50,000 |
| Total plan assets at end of year | 2012-10-31 | $191,680 |
| Total plan assets at beginning of year | 2012-10-31 | $146,356 |
| Expenses. Other expenses not covered elsewhere | 2012-10-31 | $48,670 |
| Net income (gross income less expenses) | 2012-10-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2012-10-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2012-10-31 | $0 |
| Total contributions received or receivable from employer(s) | 2012-10-31 | $50,000 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2012-10-31 | $1,330 |
| 2011 : FELIPE DOMINGUEZ, MD, PA WELFARE BENEFIT PLAN 2011 401k financial data | ||
| Total plan liabilities at end of year | 2011-10-31 | $146,356 |
| Total plan liabilities at beginning of year | 2011-10-31 | $0 |
| Total income from all sources | 2011-10-31 | $202,706 |
| Expenses. Total of all expenses incurred | 2011-10-31 | $202,706 |
| Total plan assets at end of year | 2011-10-31 | $146,356 |
| Total plan assets at beginning of year | 2011-10-31 | $0 |
| Expenses. Other expenses not covered elsewhere | 2011-10-31 | $200,206 |
| Other income received | 2011-10-31 | $6 |
| Net income (gross income less expenses) | 2011-10-31 | $0 |
| Net plan assets at end of year (total assets less liabilities) | 2011-10-31 | $0 |
| Net plan assets at beginning of year (total assets less liabilities) | 2011-10-31 | $0 |
| Total contributions received or receivable from employer(s) | 2011-10-31 | $202,700 |
| Expenses. Administrative service providers (salaries,fees and commissions) | 2011-10-31 | $2,500 |
| 2011: FELIPE DOMINGUEZ, MD, PA WELFARE BENEFIT PLAN 2011 form 5500 responses | ||
|---|---|---|
| 2011-11-01 | Type of plan entity | Single employer plan |
| 2011-11-01 | Submission has been amended | No |
| 2011-11-01 | This submission is the final filing | No |
| 2011-11-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2011-11-01 | Plan is a collectively bargained plan | No |
| 2011-11-01 | Plan funding arrangement – Insurance | Yes |
| 2011-11-01 | Plan funding arrangement – Trust | Yes |
| 2011-11-01 | Plan benefit arrangement – Insurance | Yes |
| 2011-11-01 | Plan benefit arrangement - Trust | Yes |
| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | FA-566-5842 | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||
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| EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 ) | |||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy contract number | 646787 | ||||||||||||||||||||||||||||||||||||||||||||||||||
| Policy instance | 1 | ||||||||||||||||||||||||||||||||||||||||||||||||||
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