401k Plan data: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN plan

CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 401k Plan overview

Plan Name	CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN
Plan identification number	001

CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP 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.
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.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

CHEST AND CRITICAL CARE CONSULTANTS, A.M.G., INC. has sponsored the creation of one or more 401k plans.

Company Name: CHEST AND CRITICAL CARE CONSULTANTS, A.M.G., INC.

Employer identification number (EIN): 330180540

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2023-01-01 ALLEN BURGESS 2024-10-15
001 2022-01-01 LINDA CARDOZA 2023-10-13
001 2022-01-01 ALLEN BURGESS 2024-08-21
001 2021-01-01 LINDA CARDOZA 2022-11-14
001 2020-01-01 LINDA CARDOZA 2021-10-14
001 2020-01-01 LINDA CARDOZA 2021-10-24
001 2019-01-01
001 2019-01-01
001 2018-01-01
001 2017-01-01 BOB HAYDEN 2018-05-29
001 2016-01-01 BOB HAYDEN 2017-10-03
001 2015-01-01 BOB HAYDEN 2016-09-19
001 2014-01-01 BOB HAYDEN 2015-10-06
001 2013-01-01 BOB HAYDEN 2014-09-17
001 2012-01-01 BOB HAYDEN 2013-07-10
001 2011-01-01 BOB HAYDEN 2012-10-06
001 2010-01-01 BOB HAYDEN
001 2009-01-01 HARMOHINDER GOGIA, M.D.

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2023-01-01	ALLEN BURGESS	2024-10-15
001	2022-01-01	LINDA CARDOZA	2023-10-13
001	2022-01-01	ALLEN BURGESS	2024-08-21
001	2021-01-01	LINDA CARDOZA	2022-11-14
001	2020-01-01	LINDA CARDOZA	2021-10-14
001	2020-01-01	LINDA CARDOZA	2021-10-24
001	2019-01-01
001	2019-01-01
001	2018-01-01
001	2017-01-01	BOB HAYDEN	2018-05-29
001	2016-01-01	BOB HAYDEN	2017-10-03
001	2015-01-01	BOB HAYDEN	2016-09-19
001	2014-01-01	BOB HAYDEN	2015-10-06
001	2013-01-01	BOB HAYDEN	2014-09-17
001	2012-01-01	BOB HAYDEN	2013-07-10
001	2011-01-01	BOB HAYDEN	2012-10-06
001	2010-01-01	BOB HAYDEN
001	2009-01-01	HARMOHINDER GOGIA, M.D.

Plan Statistics for CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN

401k plan membership statisitcs for CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN

Measure Date Value
2023: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 131
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 80
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 51
Total of all active and inactive participants 2023-01-01 131
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2023-01-01 0
Total participants 2023-01-01 131
Number of participants with account balances 2023-01-01 131
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2023-01-01 0
2022: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 121
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 84
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 47
Total of all active and inactive participants 2022-01-01 131
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2022-01-01 0
Total participants 2022-01-01 131
Number of participants with account balances 2022-01-01 130
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2022-01-01 0
2021: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 129
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 77
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 44
Total of all active and inactive participants 2021-01-01 121
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2021-01-01 0
Total participants 2021-01-01 121
Number of participants with account balances 2021-01-01 121
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2021-01-01 1
2020: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 98
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 31
Total of all active and inactive participants 2020-01-01 129
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 129
Number of participants with account balances 2020-01-01 129
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2010: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2010 401k membership
Total participants, beginning-of-year 2010-01-01 61
Total number of active participants reported on line 7a of the Form 5500 2010-01-01 55
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 6
Total of all active and inactive participants 2010-01-01 61
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2010-01-01 0
Total participants 2010-01-01 61
Number of participants with account balances 2010-01-01 61
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2010-01-01 0
2009: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 59
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 55
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 6
Total of all active and inactive participants 2009-01-01 61
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 61
Number of participants with account balances 2009-01-01 60
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 0

Measure	Date	Value
2023: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	131
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	80
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	51
Total of all active and inactive participants	2023-01-01	131
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2023-01-01	0
Total participants	2023-01-01	131
Number of participants with account balances	2023-01-01	131
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2023-01-01	0
2022: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	121
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	84
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	47
Total of all active and inactive participants	2022-01-01	131
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2022-01-01	0
Total participants	2022-01-01	131
Number of participants with account balances	2022-01-01	130
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2022-01-01	0
2021: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	129
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	77
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	44
Total of all active and inactive participants	2021-01-01	121
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2021-01-01	0
Total participants	2021-01-01	121
Number of participants with account balances	2021-01-01	121
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2021-01-01	1
2020: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	98
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	31
Total of all active and inactive participants	2020-01-01	129
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	129
Number of participants with account balances	2020-01-01	129
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2010: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2010 401k membership
Total participants, beginning-of-year	2010-01-01	61
Total number of active participants reported on line 7a of the Form 5500	2010-01-01	55
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	6
Total of all active and inactive participants	2010-01-01	61
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2010-01-01	0
Total participants	2010-01-01	61
Number of participants with account balances	2010-01-01	61
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2010-01-01	0
2009: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	59
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	55
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	6
Total of all active and inactive participants	2009-01-01	61
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	61
Number of participants with account balances	2009-01-01	60
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	0

Financial Data on CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN

Measure	Date	Value
2023 : CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2023 401k financial data
Total unrealized appreciation/depreciation of assets	2023-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2023-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2023-12-31	$0
Total income from all sources (including contributions)	2023-12-31	$4,393,822
Total loss/gain on sale of assets	2023-12-31	$0
Total of all expenses incurred	2023-12-31	$596,617
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2023-12-31	$578,451
Expenses. Certain deemed distributions of participant loans	2023-12-31	$5,175
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2023-12-31	$1,278,410
Value of total assets at end of year	2023-12-31	$22,358,192
Value of total assets at beginning of year	2023-12-31	$18,560,987
Total of administrative expenses incurred including professional, contract, advisory and management fees	2023-12-31	$12,991
Total interest from all sources	2023-12-31	$2,939
Total dividends received (eg from common stock, registered investment company shares)	2023-12-31	$348,382
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2023-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2023-12-31	$348,382
Was this plan covered by a fidelity bond	2023-12-31	Yes
Value of fidelity bond cover	2023-12-31	$500,000
If this is an individual account plan, was there a blackout period	2023-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2023-12-31	No
Contributions received from participants	2023-12-31	$855,054
Participant contributions at end of year	2023-12-31	$38,268
Participant contributions at beginning of year	2023-12-31	$54,258
Participant contributions at end of year	2023-12-31	$32,167
Participant contributions at beginning of year	2023-12-31	$15,965
Assets. Other investments not covered elsewhere at end of year	2023-12-31	$1,322,527
Assets. Other investments not covered elsewhere at beginning of year	2023-12-31	$1,141,164
Other income not declared elsewhere	2023-12-31	$45,338
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2023-12-31	No
Value of net income/loss	2023-12-31	$3,797,205
Value of net assets at end of year (total assets less liabilities)	2023-12-31	$22,358,192
Value of net assets at beginning of year (total assets less liabilities)	2023-12-31	$18,560,987
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2023-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2023-12-31	No
Were any leases to which the plan was party in default or uncollectible	2023-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2023-12-31	$15,724,114
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2023-12-31	$12,716,589
Income. Interest from loans (other than to participants)	2023-12-31	$2,939
Value of interest in common/collective trusts at end of year	2023-12-31	$546,154
Value of interest in common/collective trusts at beginning of year	2023-12-31	$513,101
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2023-12-31	$845,832
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2023-12-31	$231,109
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2023-12-31	$231,109
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2023-12-31	$2,718,753
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2023-12-31	No
Was there a failure to transmit to the plan any participant contributions	2023-12-31	No
Has the plan failed to provide any benefit when due under the plan	2023-12-31	No
Contributions received in cash from employer	2023-12-31	$423,356
Employer contributions (assets) at end of year	2023-12-31	$143,382
Employer contributions (assets) at beginning of year	2023-12-31	$173,580
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2023-12-31	$578,451
Contract administrator fees	2023-12-31	$12,991
Assets. Corporate common stocks other than exployer securities at end of year	2023-12-31	$3,705,748
Assets. Corporate common stocks other than exployer securities at beginning of year	2023-12-31	$3,715,221
Did the plan have assets held for investment	2023-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2023-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2023-12-31	No
Opinion of an independent qualified public accountant for this plan	2023-12-31	Unqualified
Accountancy firm name	2023-12-31	LANCE, SOLL & LUNDHARD, LLP
Accountancy firm EIN	2023-12-31	952700123
2022 : CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2022 401k financial data
Total unrealized appreciation/depreciation of assets	2022-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2022-12-31	$0
Total income from all sources (including contributions)	2022-12-31	$-2,696,190
Total loss/gain on sale of assets	2022-12-31	$0
Total of all expenses incurred	2022-12-31	$238,948
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2022-12-31	$233,475
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2022-12-31	$1,179,053
Value of total assets at end of year	2022-12-31	$18,558,072
Value of total assets at beginning of year	2022-12-31	$21,493,210
Total of administrative expenses incurred including professional, contract, advisory and management fees	2022-12-31	$5,473
Total interest from all sources	2022-12-31	$3,656
Total dividends received (eg from common stock, registered investment company shares)	2022-12-31	$290,094
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2022-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2022-12-31	$290,094
Was this plan covered by a fidelity bond	2022-12-31	Yes
Value of fidelity bond cover	2022-12-31	$500,000
If this is an individual account plan, was there a blackout period	2022-12-31	No
Were there any nonexempt tranactions with any party-in-interest	2022-12-31	No
Contributions received from participants	2022-12-31	$773,798
Participant contributions at end of year	2022-12-31	$54,258
Participant contributions at beginning of year	2022-12-31	$67,961
Participant contributions at end of year	2022-12-31	$15,965
Participant contributions at beginning of year	2022-12-31	$21,957
Assets. Other investments not covered elsewhere at end of year	2022-12-31	$1,141,164
Assets. Other investments not covered elsewhere at beginning of year	2022-12-31	$1,391,477
Income. Received or receivable in cash from other sources (including rollovers)	2022-12-31	$15,725
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Value of net income/loss	2022-12-31	$-2,935,138
Value of net assets at end of year (total assets less liabilities)	2022-12-31	$18,558,072
Value of net assets at beginning of year (total assets less liabilities)	2022-12-31	$21,493,210
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2022-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2022-12-31	No
Were any leases to which the plan was party in default or uncollectible	2022-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2022-12-31	$12,716,589
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2022-12-31	$14,732,388
Income. Interest from loans (other than to participants)	2022-12-31	$3,656
Value of interest in common/collective trusts at end of year	2022-12-31	$513,101
Value of interest in common/collective trusts at beginning of year	2022-12-31	$259,158
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2022-12-31	$231,109
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2022-12-31	$490,062
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2022-12-31	$490,062
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2022-12-31	$-4,168,993
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2022-12-31	No
Was there a failure to transmit to the plan any participant contributions	2022-12-31	No
Has the plan failed to provide any benefit when due under the plan	2022-12-31	No
Contributions received in cash from employer	2022-12-31	$389,530
Employer contributions (assets) at end of year	2022-12-31	$170,665
Employer contributions (assets) at beginning of year	2022-12-31	$130,605
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2022-12-31	$233,475
Contract administrator fees	2022-12-31	$5,473
Assets. Corporate common stocks other than exployer securities at end of year	2022-12-31	$3,715,221
Assets. Corporate common stocks other than exployer securities at beginning of year	2022-12-31	$4,399,602
Did the plan have assets held for investment	2022-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2022-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2022-12-31	No
Opinion of an independent qualified public accountant for this plan	2022-12-31	Unqualified
Accountancy firm name	2022-12-31	ROORDA, PIQUET & BESSEE, INC.
Accountancy firm EIN	2022-12-31	330252865
2021 : CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2021 401k financial data
Total unrealized appreciation/depreciation of assets	2021-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2021-12-31	$0
Total income from all sources (including contributions)	2021-12-31	$4,303,642
Total loss/gain on sale of assets	2021-12-31	$0
Total of all expenses incurred	2021-12-31	$6,987,015
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2021-12-31	$6,986,190
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2021-12-31	$1,243,692
Value of total assets at end of year	2021-12-31	$21,491,660
Value of total assets at beginning of year	2021-12-31	$24,175,033
Total of administrative expenses incurred including professional, contract, advisory and management fees	2021-12-31	$825
Total interest from all sources	2021-12-31	$4,335
Total dividends received (eg from common stock, registered investment company shares)	2021-12-31	$298,299
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2021-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2021-12-31	$298,299
Was this plan covered by a fidelity bond	2021-12-31	Yes
Value of fidelity bond cover	2021-12-31	$500,000
If this is an individual account plan, was there a blackout period	2021-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2021-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2021-12-31	No
Contributions received from participants	2021-12-31	$843,088
Participant contributions at end of year	2021-12-31	$67,961
Participant contributions at beginning of year	2021-12-31	$57,377
Participant contributions at end of year	2021-12-31	$21,957
Participant contributions at beginning of year	2021-12-31	$20,439
Assets. Other investments not covered elsewhere at end of year	2021-12-31	$1,391,477
Assets. Other investments not covered elsewhere at beginning of year	2021-12-31	$1,278,057
Income. Received or receivable in cash from other sources (including rollovers)	2021-12-31	$44,380
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Value of net income/loss	2021-12-31	$-2,683,373
Value of net assets at end of year (total assets less liabilities)	2021-12-31	$21,491,660
Value of net assets at beginning of year (total assets less liabilities)	2021-12-31	$24,175,033
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2021-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2021-12-31	No
Were any leases to which the plan was party in default or uncollectible	2021-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2021-12-31	$14,055,630
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2021-12-31	$17,888,582
Interest on participant loans	2021-12-31	$4,335
Value of interest in common/collective trusts at end of year	2021-12-31	$256,158
Value of interest in common/collective trusts at beginning of year	2021-12-31	$510,020
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2021-12-31	$504,235
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2021-12-31	$502,358
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2021-12-31	$502,358
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2021-12-31	$2,757,316
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2021-12-31	No
Was there a failure to transmit to the plan any participant contributions	2021-12-31	No
Has the plan failed to provide any benefit when due under the plan	2021-12-31	No
Contributions received in cash from employer	2021-12-31	$356,224
Employer contributions (assets) at end of year	2021-12-31	$128,956
Employer contributions (assets) at beginning of year	2021-12-31	$210,735
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2021-12-31	$6,986,190
Contract administrator fees	2021-12-31	$825
Assets. Corporate common stocks other than exployer securities at end of year	2021-12-31	$5,065,286
Assets. Corporate common stocks other than exployer securities at beginning of year	2021-12-31	$3,707,465
Did the plan have assets held for investment	2021-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2021-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2021-12-31	No
Opinion of an independent qualified public accountant for this plan	2021-12-31	Disclaimer
Accountancy firm name	2021-12-31	ROORDA, PIQUET & BESSEE, INC.
Accountancy firm EIN	2021-12-31	330252865
2020 : CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-12-31	$0
Total income from all sources (including contributions)	2020-12-31	$4,746,858
Total loss/gain on sale of assets	2020-12-31	$0
Total of all expenses incurred	2020-12-31	$183,781
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-12-31	$176,019
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-12-31	$1,197,409
Value of total assets at end of year	2020-12-31	$24,175,033
Value of total assets at beginning of year	2020-12-31	$19,611,956
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-12-31	$7,762
Total interest from all sources	2020-12-31	$2,561
Total dividends received (eg from common stock, registered investment company shares)	2020-12-31	$239,523
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-12-31	No
Total dividends received from registered investment company shares (eg mutual funds)	2020-12-31	$239,523
Was this plan covered by a fidelity bond	2020-12-31	Yes
Value of fidelity bond cover	2020-12-31	$500,000
If this is an individual account plan, was there a blackout period	2020-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2020-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2020-12-31	No
Contributions received from participants	2020-12-31	$756,584
Participant contributions at end of year	2020-12-31	$57,377
Participant contributions at beginning of year	2020-12-31	$4,837
Participant contributions at end of year	2020-12-31	$20,439
Participant contributions at beginning of year	2020-12-31	$0
Assets. Other investments not covered elsewhere at end of year	2020-12-31	$1,278,057
Assets. Other investments not covered elsewhere at beginning of year	2020-12-31	$1,154,257
Income. Received or receivable in cash from other sources (including rollovers)	2020-12-31	$27,899
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Value of net income/loss	2020-12-31	$4,563,077
Value of net assets at end of year (total assets less liabilities)	2020-12-31	$24,175,033
Value of net assets at beginning of year (total assets less liabilities)	2020-12-31	$19,611,956
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-12-31	No
Were any leases to which the plan was party in default or uncollectible	2020-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-12-31	$17,888,582
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-12-31	$13,384,399
Interest on participant loans	2020-12-31	$2,561
Value of interest in common/collective trusts at end of year	2020-12-31	$510,020
Value of interest in common/collective trusts at beginning of year	2020-12-31	$1,956,299
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2020-12-31	$502,358
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2020-12-31	$1,968,519
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2020-12-31	$1,968,519
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-12-31	$3,307,365
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-12-31	No
Was there a failure to transmit to the plan any participant contributions	2020-12-31	No
Has the plan failed to provide any benefit when due under the plan	2020-12-31	No
Contributions received in cash from employer	2020-12-31	$412,926
Employer contributions (assets) at end of year	2020-12-31	$210,735
Employer contributions (assets) at beginning of year	2020-12-31	$223,963
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-12-31	$176,019
Contract administrator fees	2020-12-31	$7,762
Assets. Corporate common stocks other than exployer securities at end of year	2020-12-31	$3,707,465
Assets. Corporate common stocks other than exployer securities at beginning of year	2020-12-31	$919,682
Did the plan have assets held for investment	2020-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-12-31	No
Opinion of an independent qualified public accountant for this plan	2020-12-31	Disclaimer
Accountancy firm name	2020-12-31	ROORDA, PIQUET & BESSEE, INC.
Accountancy firm EIN	2020-12-31	330252865
2010 : CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2010 401k financial data
Total income from all sources	2010-12-31	$1,409,490
Expenses. Total of all expenses incurred	2010-12-31	$13,147
Benefits paid (including direct rollovers)	2010-12-31	$13,147
Total plan assets at end of year	2010-12-31	$8,659,593
Total plan assets at beginning of year	2010-12-31	$7,263,250
Value of fidelity bond covering the plan	2010-12-31	$500,000
Total contributions received or receivable from participants	2010-12-31	$342,363
Expenses. Other expenses not covered elsewhere	2010-12-31	$0
Contributions received from other sources (not participants or employers)	2010-12-31	$0
Other income received	2010-12-31	$826,074
Noncash contributions received	2010-12-31	$0
Net income (gross income less expenses)	2010-12-31	$1,396,343
Net plan assets at end of year (total assets less liabilities)	2010-12-31	$8,659,593
Net plan assets at beginning of year (total assets less liabilities)	2010-12-31	$7,263,250
Assets. Value of assets in partnership/joint-venture interests	2010-12-31	$203,555
Total contributions received or receivable from employer(s)	2010-12-31	$241,053
Value of certain deemed distributions of participant loans	2010-12-31	$0
Value of corrective distributions	2010-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2010-12-31	$0
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
2009 : CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2009 401k financial data
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2009-12-31	$0

Form 5500 Responses for CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN

2023: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Submission has been amended	No
2023-01-01	This submission is the final filing	No
2023-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-01-01	Plan is a collectively bargained plan	No
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – Trust	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement - Trust	Yes
2022: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Submission has been amended	Yes
2022-01-01	This submission is the final filing	No
2022-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2022-01-01	Plan is a collectively bargained plan	No
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan funding arrangement – Trust	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement - Trust	Yes
2021: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Submission has been amended	Yes
2021-01-01	This submission is the final filing	No
2021-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2021-01-01	Plan is a collectively bargained plan	No
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan funding arrangement – Trust	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement - Trust	Yes
2020: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	Yes
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 – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2010: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2010 form 5500 responses
2010-01-01	Type of plan entity	Single employer plan
2010-01-01	Submission has been amended	No
2010-01-01	This submission is the final filing	No
2010-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2010-01-01	Plan is a collectively bargained plan	No
2010-01-01	Plan funding arrangement – Insurance	Yes
2010-01-01	Plan funding arrangement – Trust	Yes
2010-01-01	Plan benefit arrangement – Insurance	Yes
2010-01-01	Plan benefit arrangement - Trust	Yes
2009: CHEST AND CRITICAL CARE CONSULTANTS, A MEDICAL GROUP PROFIT SHARING PLAN 2009 form 5500 responses
2009-01-01	Type of plan entity	Single employer plan
2009-01-01	Submission has been amended	No
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 funding arrangement – Trust	Yes
2009-01-01	Plan benefit arrangement – Insurance	Yes
2009-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1006582326

Policy instance

Insurance contract or identification number	1006582326
Number of Individuals Covered	1
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
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?	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	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?	Yes

ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

DAVO5305

Policy instance

Insurance contract or identification number	DAVO5305
Number of Individuals Covered	1
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

009126753A

Policy instance

Insurance contract or identification number	009126753A
Number of Individuals Covered	1
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1010467485

Policy instance

Insurance contract or identification number	1010467485
Number of Individuals Covered	1
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
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?	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	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?	Yes

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

Policy contract number

711131745

Policy instance

Insurance contract or identification number	711131745
Number of Individuals Covered	1
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1006546850

Policy instance

Insurance contract or identification number	1006546850
Number of Individuals Covered	1
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1010467647

Policy instance

Insurance contract or identification number	1010467647
Number of Individuals Covered	1
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

009126753A

Policy instance

Insurance contract or identification number	009126753A
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1010467485

Policy instance

Insurance contract or identification number	1010467485
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	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	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?	Yes

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

Policy contract number

711131745

Policy instance

Insurance contract or identification number	711131745
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1006546850

Policy instance

Insurance contract or identification number	1006546850
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1010467647

Policy instance

Insurance contract or identification number	1010467647
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1006582326

Policy instance

Insurance contract or identification number	1006582326
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	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	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?	Yes

ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

DAVO5305

Policy instance

Insurance contract or identification number	DAVO5305
Number of Individuals Covered	1
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1006582326

Policy instance

Insurance contract or identification number	1006582326
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1010467647

Policy instance

Insurance contract or identification number	1010467647
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1006546850

Policy instance

Insurance contract or identification number	1006546850
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	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	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?	Yes

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

Policy contract number

711131745

Policy instance

Insurance contract or identification number	711131745
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1010467485

Policy instance

Insurance contract or identification number	1010467485
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

009126753A

Policy instance

Insurance contract or identification number	009126753A
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	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	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?	Yes

ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

DAVO5305

Policy instance

Insurance contract or identification number	DAVO5305
Number of Individuals Covered	1
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
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?	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	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?	Yes

ALLIANZ LIFE INSURANCE COMPANY OF NORTH AMERICA (National Association of Insurance Commissioners NAIC id number: 90611 )

Policy contract number

DAVO5305

Policy instance

Insurance contract or identification number	DAVO5305
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

009126753A

Policy instance

Insurance contract or identification number	009126753A
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1010467485

Policy instance

Insurance contract or identification number	1010467485
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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?	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	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?	Yes

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

Policy contract number

711131745

Policy instance

Insurance contract or identification number	711131745
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1006546850

Policy instance

Insurance contract or identification number	1006546850
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1010467647

Policy instance

Insurance contract or identification number	1010467647
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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?	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	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?	Yes

JACKSON NATIONAL (National Association of Insurance Commissioners NAIC id number: 65056 )

Policy contract number

1006582326

Policy instance

Insurance contract or identification number	1006582326
Number of Individuals Covered	1
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
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?	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	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?	Yes

MINNESOTA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66168 )

Policy contract number

1584307V

Policy instance

Insurance contract or identification number	1584307V
Number of Individuals Covered	1
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	Yes
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	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?	Yes

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Company Name:	CHEST AND CRITICAL CARE CONSULTANTS, A.M.G., INC.
Employer identification number (EIN):	330180540
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)