401k Plan data: MERCER EYE ASSOCIATES 401K PS PLAN plan

MERCER EYE ASSOCIATES 401K PS PLAN 401k Plan overview

Plan Name	MERCER EYE ASSOCIATES 401K PS PLAN
Plan identification number	002

MERCER EYE ASSOCIATES 401K PS PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

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.
Partial participant-directed account plan - Participants have the opportunity to direct the investment of a portion of 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.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
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

MERCER EYE ASSOCIATES, P.A. has sponsored the creation of one or more 401k plans.

Company Name: MERCER EYE ASSOCIATES, P.A.

Employer identification number (EIN): 221907430

NAIC Classification: 621399
NAIC Description: Offices of All Other Miscellaneous Health Practitioners

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MERCER EYE ASSOCIATES 401K PS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
002 2022-01-01 MICHELE DOMBROWSKI 2023-09-20
002 2021-01-01 MICHELE DOMBROWSKI 2022-07-27 MERCER EYE ASSOCIATES 2022-07-27
002 2020-01-01 MICHELE DOMBROWSKI 2021-07-20
002 2019-01-01 MICHELE DOMBROWSKI 2020-07-30
002 2018-01-01 MICHELE DOMBROWSKI 2019-07-11
002 2017-01-01 MICHELE DOMBROWSKI 2018-07-27
002 2016-01-01 MICHELE 2017-07-20
002 2015-01-01 MICHELE DOMBROWSKI 2016-07-14
002 2014-01-01 MICHELE DOMBROWSKI
002 2013-01-01 JOY GORSKI JOY GORSKI 2014-07-29
002 2012-01-01 JOY GORSKI
002 2011-01-01 ROBERT CHIANG, MD
002 2010-01-01 BELANGER AND CO., INC. ROBERT CHIANG, MD 2011-10-31
002 2009-01-01 ROBERT CHIANG, MD

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
002	2022-01-01	MICHELE DOMBROWSKI	2023-09-20
002	2021-01-01	MICHELE DOMBROWSKI	2022-07-27	MERCER EYE ASSOCIATES	2022-07-27
002	2020-01-01	MICHELE DOMBROWSKI	2021-07-20
002	2019-01-01	MICHELE DOMBROWSKI	2020-07-30
002	2018-01-01	MICHELE DOMBROWSKI	2019-07-11
002	2017-01-01	MICHELE DOMBROWSKI	2018-07-27
002	2016-01-01	MICHELE	2017-07-20
002	2015-01-01	MICHELE DOMBROWSKI	2016-07-14
002	2014-01-01	MICHELE DOMBROWSKI
002	2013-01-01	JOY GORSKI		JOY GORSKI	2014-07-29
002	2012-01-01	JOY GORSKI
002	2011-01-01	ROBERT CHIANG, MD
002	2010-01-01	BELANGER AND CO., INC.		ROBERT CHIANG, MD	2011-10-31
002	2009-01-01	ROBERT CHIANG, MD

Plan Statistics for MERCER EYE ASSOCIATES 401K PS PLAN

401k plan membership statisitcs for MERCER EYE ASSOCIATES 401K PS PLAN

Measure Date Value
2014: MERCER EYE ASSOCIATES 401K PS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 23
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 25
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 25
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 25
Number of participants with account balances 2014-01-01 20
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 0
2013: MERCER EYE ASSOCIATES 401K PS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 26
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 26
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 3
Total of all active and inactive participants 2013-01-01 29
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 29
Number of participants with account balances 2013-01-01 25
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 0
2012: MERCER EYE ASSOCIATES 401K PS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 26
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 26
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 5
Total of all active and inactive participants 2012-01-01 31
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 31
Number of participants with account balances 2012-01-01 26
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 2
2011: MERCER EYE ASSOCIATES 401K PS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 23
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 23
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 23
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 23
Number of participants with account balances 2011-01-01 23
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 0
2010: MERCER EYE ASSOCIATES 401K PS PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 21
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 23
Number of retired or separated participants receiving benefits 2010-01-01 0
Number of other retired or separated participants entitled to future benefits 2010-01-01 0
Total of all active and inactive participants 2010-01-01 23
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 23
Number of participants with account balances 2010-01-01 23
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: MERCER EYE ASSOCIATES 401K PS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 24
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 21
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 21
Total participants 2009-01-01 21
Number of participants with account balances 2009-01-01 21
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2014: MERCER EYE ASSOCIATES 401K PS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	23
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	25
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	25
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	25
Number of participants with account balances	2014-01-01	20
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	0
2013: MERCER EYE ASSOCIATES 401K PS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	26
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	26
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	3
Total of all active and inactive participants	2013-01-01	29
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	29
Number of participants with account balances	2013-01-01	25
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	0
2012: MERCER EYE ASSOCIATES 401K PS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	26
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	26
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	5
Total of all active and inactive participants	2012-01-01	31
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	31
Number of participants with account balances	2012-01-01	26
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	2
2011: MERCER EYE ASSOCIATES 401K PS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	23
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	23
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	23
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	23
Number of participants with account balances	2011-01-01	23
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	0
2010: MERCER EYE ASSOCIATES 401K PS PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	21
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	23
Number of retired or separated participants receiving benefits	2010-01-01	0
Number of other retired or separated participants entitled to future benefits	2010-01-01	0
Total of all active and inactive participants	2010-01-01	23
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	23
Number of participants with account balances	2010-01-01	23
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: MERCER EYE ASSOCIATES 401K PS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	24
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	21
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	21
Total participants	2009-01-01	21
Number of participants with account balances	2009-01-01	21
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on MERCER EYE ASSOCIATES 401K PS PLAN

Measure	Date	Value
2014 : MERCER EYE ASSOCIATES 401K PS PLAN 2014 401k financial data
Total income from all sources	2014-12-31	$337,203
Expenses. Total of all expenses incurred	2014-12-31	$34,567
Benefits paid (including direct rollovers)	2014-12-31	$32,996
Total plan assets at end of year	2014-12-31	$2,987,519
Total plan assets at beginning of year	2014-12-31	$2,684,883
Value of fidelity bond covering the plan	2014-12-31	$275,000
Total contributions received or receivable from participants	2014-12-31	$89,878
Expenses. Other expenses not covered elsewhere	2014-12-31	$1,571
Contributions received from other sources (not participants or employers)	2014-12-31	$0
Other income received	2014-12-31	$144,473
Net income (gross income less expenses)	2014-12-31	$302,636
Net plan assets at end of year (total assets less liabilities)	2014-12-31	$2,987,519
Net plan assets at beginning of year (total assets less liabilities)	2014-12-31	$2,684,883
Assets. Value of participant loans	2014-12-31	$51,061
Total contributions received or receivable from employer(s)	2014-12-31	$102,852
Value of certain deemed distributions of participant loans	2014-12-31	$0
Value of corrective distributions	2014-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2014-12-31	$0
Minimum employer required contribution for this plan year	2014-12-31	$0
Amount contributed by the employer to the plan for this plan year	2014-12-31	$0
2013 : MERCER EYE ASSOCIATES 401K PS PLAN 2013 401k financial data
Transfers to/from the plan	2013-12-31	$0
Total income from all sources	2013-12-31	$551,126
Expenses. Total of all expenses incurred	2013-12-31	$9,299
Benefits paid (including direct rollovers)	2013-12-31	$9,114
Total plan assets at end of year	2013-12-31	$2,684,883
Total plan assets at beginning of year	2013-12-31	$2,143,056
Value of fidelity bond covering the plan	2013-12-31	$200,000
Total contributions received or receivable from participants	2013-12-31	$80,953
Expenses. Other expenses not covered elsewhere	2013-12-31	$185
Contributions received from other sources (not participants or employers)	2013-12-31	$0
Other income received	2013-12-31	$376,223
Net income (gross income less expenses)	2013-12-31	$541,827
Net plan assets at end of year (total assets less liabilities)	2013-12-31	$2,684,883
Net plan assets at beginning of year (total assets less liabilities)	2013-12-31	$2,143,056
Assets. Value of participant loans	2013-12-31	$62,150
Total contributions received or receivable from employer(s)	2013-12-31	$93,950
Value of certain deemed distributions of participant loans	2013-12-31	$0
Value of corrective distributions	2013-12-31	$0
Funding deficiency by the employer to the plan for this plan year	2013-12-31	$0
Minimum employer required contribution for this plan year	2013-12-31	$0
Amount contributed by the employer to the plan for this plan year	2013-12-31	$0
2012 : MERCER EYE ASSOCIATES 401K PS PLAN 2012 401k financial data
Total income from all sources	2012-12-31	$437,634
Expenses. Total of all expenses incurred	2012-12-31	$130,010
Benefits paid (including direct rollovers)	2012-12-31	$129,598
Total plan assets at end of year	2012-12-31	$2,143,056
Total plan assets at beginning of year	2012-12-31	$1,835,432
Value of fidelity bond covering the plan	2012-12-31	$200,000
Total contributions received or receivable from participants	2012-12-31	$65,764
Expenses. Other expenses not covered elsewhere	2012-12-31	$412
Contributions received from other sources (not participants or employers)	2012-12-31	$0
Other income received	2012-12-31	$310,190
Net income (gross income less expenses)	2012-12-31	$307,624
Net plan assets at end of year (total assets less liabilities)	2012-12-31	$2,143,056
Net plan assets at beginning of year (total assets less liabilities)	2012-12-31	$1,835,432
Assets. Value of participant loans	2012-12-31	$67,744
Total contributions received or receivable from employer(s)	2012-12-31	$61,680
Value of certain deemed distributions of participant loans	2012-12-31	$0
Value of corrective distributions	2012-12-31	$0
2011 : MERCER EYE ASSOCIATES 401K PS PLAN 2011 401k financial data
Total plan liabilities at end of year	2011-12-31	$0
Total plan liabilities at beginning of year	2011-12-31	$0
Total income from all sources	2011-12-31	$141,192
Expenses. Total of all expenses incurred	2011-12-31	$15,000
Benefits paid (including direct rollovers)	2011-12-31	$15,000
Total plan assets at end of year	2011-12-31	$1,835,432
Total plan assets at beginning of year	2011-12-31	$1,709,240
Total contributions received or receivable from participants	2011-12-31	$65,589
Other income received	2011-12-31	$38,110
Net income (gross income less expenses)	2011-12-31	$126,192
Net plan assets at end of year (total assets less liabilities)	2011-12-31	$1,835,432
Net plan assets at beginning of year (total assets less liabilities)	2011-12-31	$1,709,240
Assets. Value of participant loans	2011-12-31	$88,308
Total contributions received or receivable from employer(s)	2011-12-31	$37,493
2010 : MERCER EYE ASSOCIATES 401K PS PLAN 2010 401k financial data
Total plan liabilities at end of year	2010-12-31	$0
Total plan liabilities at beginning of year	2010-12-31	$0
Total income from all sources	2010-12-31	$304,828
Expenses. Total of all expenses incurred	2010-12-31	$36,558
Benefits paid (including direct rollovers)	2010-12-31	$36,558
Total plan assets at end of year	2010-12-31	$1,709,240
Total plan assets at beginning of year	2010-12-31	$1,440,970
Total contributions received or receivable from participants	2010-12-31	$68,381
Other income received	2010-12-31	$168,697
Net income (gross income less expenses)	2010-12-31	$268,270
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$1,709,240
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$1,440,970
Assets. Value of participant loans	2010-12-31	$61,720
Total contributions received or receivable from employer(s)	2010-12-31	$67,750

Form 5500 Responses for MERCER EYE ASSOCIATES 401K PS PLAN

2014: MERCER EYE ASSOCIATES 401K PS 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 funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2013: MERCER EYE ASSOCIATES 401K PS 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 funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2012: MERCER EYE ASSOCIATES 401K PS 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 funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2011: MERCER EYE ASSOCIATES 401K PS PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2010: MERCER EYE ASSOCIATES 401K PS PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: MERCER EYE ASSOCIATES 401K PS PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Plan funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-830238

Policy instance

Insurance contract or identification number	GA-830238
Number of Individuals Covered	20
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,365
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?	Yes
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 $5,365
Insurance broker organization code?	3
Insurance broker name	SANTANDER SECURITIES LLC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-830238

Policy instance

Insurance contract or identification number	GA-830238
Number of Individuals Covered	25
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $3,684
Total amount of fees paid to insurance company	USD $35
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?	Yes
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 $2,374
Insurance broker organization code?	3
Amount paid for insurance broker fees	35
Additional information about fees paid to insurance broker	SALES/MARKETING
Insurance broker name	LPL FINANCIAL LLC

HARTFORD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 88072 )

Policy contract number

GA-830238

Policy instance

Insurance contract or identification number	GA-830238
Number of Individuals Covered	26
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $30,851
Total amount of fees paid to insurance company	USD $32
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?	Yes
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 $30,851
Insurance broker organization code?	3
Amount paid for insurance broker fees	32
Additional information about fees paid to insurance broker	SALES/MARKETING
Insurance broker name	LPL FINANCIAL LLC

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Company Name:	MERCER EYE ASSOCIATES, P.A.
Employer identification number (EIN):	221907430
NAIC Classification:	621399
NAIC Description:	Offices of All Other Miscellaneous Health Practitioners