401k Plan data: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN plan

BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 401k Plan overview

Plan Name	BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN
Plan identification number	501

BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

BLUE RIDGE BONE & JOINT CLINIC, P.A has sponsored the creation of one or more 401k plans.

Company Name: BLUE RIDGE BONE & JOINT CLINIC, P.A

Employer identification number (EIN): 560951119

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-09-01
501 2014-09-01
501 2013-09-01
501 2012-09-01 JUDY WEBSTER
501 2011-09-01 JUDY WEBSTER
501 2009-09-01 JUDY WEBSTER

Plan Statistics for BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN

401k plan membership statisitcs for BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN

Measure Date Value
2015: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-09-01 140
Total number of active participants reported on line 7a of the Form 5500 2015-09-01 0
Total of all active and inactive participants 2015-09-01 0
2014: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-09-01 132
Total number of active participants reported on line 7a of the Form 5500 2014-09-01 140
Total of all active and inactive participants 2014-09-01 140
Total participants 2014-09-01 140
2013: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-09-01 161
Total number of active participants reported on line 7a of the Form 5500 2013-09-01 132
Total of all active and inactive participants 2013-09-01 132
2012: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-09-01 134
Total number of active participants reported on line 7a of the Form 5500 2012-09-01 161
Total of all active and inactive participants 2012-09-01 161
2011: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-09-01 130
Total number of active participants reported on line 7a of the Form 5500 2011-09-01 134
Total of all active and inactive participants 2011-09-01 134
2009: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-09-01 126
Total number of active participants reported on line 7a of the Form 5500 2009-09-01 135
Total of all active and inactive participants 2009-09-01 135

Measure	Date	Value
2015: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-09-01	140
Total number of active participants reported on line 7a of the Form 5500	2015-09-01	0
Total of all active and inactive participants	2015-09-01	0
2014: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-09-01	132
Total number of active participants reported on line 7a of the Form 5500	2014-09-01	140
Total of all active and inactive participants	2014-09-01	140
Total participants	2014-09-01	140
2013: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-09-01	161
Total number of active participants reported on line 7a of the Form 5500	2013-09-01	132
Total of all active and inactive participants	2013-09-01	132
2012: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-09-01	134
Total number of active participants reported on line 7a of the Form 5500	2012-09-01	161
Total of all active and inactive participants	2012-09-01	161
2011: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-09-01	130
Total number of active participants reported on line 7a of the Form 5500	2011-09-01	134
Total of all active and inactive participants	2011-09-01	134
2009: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-09-01	126
Total number of active participants reported on line 7a of the Form 5500	2009-09-01	135
Total of all active and inactive participants	2009-09-01	135

Form 5500 Responses for BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN

2015: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2015 form 5500 responses
2015-09-01	Type of plan entity	Single employer plan
2015-09-01	This submission is the final filing	Yes
2015-09-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2015-09-01	Plan funding arrangement – Insurance	Yes
2015-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2015-09-01	Plan benefit arrangement – Insurance	Yes
2015-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2014: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2014 form 5500 responses
2014-09-01	Type of plan entity	Single employer plan
2014-09-01	Plan funding arrangement – Insurance	Yes
2014-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2014-09-01	Plan benefit arrangement – Insurance	Yes
2014-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2013: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2013 form 5500 responses
2013-09-01	Type of plan entity	Single employer plan
2013-09-01	Plan funding arrangement – Insurance	Yes
2013-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2013-09-01	Plan benefit arrangement – Insurance	Yes
2013-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2012: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2012 form 5500 responses
2012-09-01	Type of plan entity	Single employer plan
2012-09-01	Plan funding arrangement – Insurance	Yes
2012-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2012-09-01	Plan benefit arrangement – Insurance	Yes
2012-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2011: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2011 form 5500 responses
2011-09-01	Type of plan entity	Single employer plan
2011-09-01	Plan funding arrangement – Insurance	Yes
2011-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2011-09-01	Plan benefit arrangement – Insurance	Yes
2011-09-01	Plan benefit arrangement – General assets of the sponsor	Yes
2009: BLUE RIDGE BONE & JOINT FLEXIBLE BENEFITS PLAN 2009 form 5500 responses
2009-09-01	Type of plan entity	Single employer plan
2009-09-01	This submission is the final filing	No
2009-09-01	Plan funding arrangement – Insurance	Yes
2009-09-01	Plan funding arrangement – General assets of the sponsor	Yes
2009-09-01	Plan benefit arrangement – Insurance	Yes
2009-09-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7531411

Policy instance

Insurance contract or identification number	E7531411
Number of Individuals Covered	51
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $13,027
Total amount of fees paid to insurance company	USD $1,249
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSP INC INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $69,318
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,410
Amount paid for insurance broker fees	800
Additional information about fees paid to insurance broker	OTHER FEES
Insurance broker organization code?	3
Insurance broker name	KEENA S. GEORGE

DELTA DENTAL OF NORTH CAROLINA (National Association of Insurance Commissioners NAIC id number: 54658 )

Policy contract number

891

Policy instance

Insurance contract or identification number	891
Number of Individuals Covered	164
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $5,812
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,812
Insurance broker organization code?	3
Insurance broker name	COLTON GROOME BENEFIT ADVISORS, LLC

J ALLAN HALL AND ASSOCIATES (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

SAJAH1006010114

Policy instance

Insurance contract or identification number	SAJAH1006010114
Number of Individuals Covered	119
Insurance policy start date	2016-01-01
Insurance policy end date	2016-12-31
Total amount of commissions paid to insurance broker	USD $24,056
Total amount of fees paid to insurance company	USD $0
Welfare Benefit Premiums Paid to Carrier	USD $153,483
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $18,269
Insurance broker organization code?	5
Insurance broker name	INTEGRA BENEFIT ADVISORS

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

LIF/LTD30640

Policy instance

Insurance contract or identification number	LIF/LTD30640
Number of Individuals Covered	143
Insurance policy start date	2016-01-01
Insurance policy end date	2016-07-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $76,023
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Insurance broker organization code?	3
Insurance broker name

J ALLAN HALL AND ASSOCIATES (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

SAJAH1006010114

Policy instance

Insurance contract or identification number	SAJAH1006010114
Number of Individuals Covered	120
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $21,735
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $130,367
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $16,128
Insurance broker organization code?	3
Insurance broker name	INTEGRA BENEFIT ADVISORS

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

LIF/LTD30640

Policy instance

Insurance contract or identification number	LIF/LTD30640
Number of Individuals Covered	140
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $10,623
Total amount of fees paid to insurance company	USD $180
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $133,966
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,623
Insurance broker organization code?	3
Amount paid for insurance broker fees	180
Additional information about fees paid to insurance broker	FEES
Insurance broker name	MEDICAL GROUP INSURANCE SERVICES

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7531411

Policy instance

Insurance contract or identification number	E7531411
Number of Individuals Covered	53
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $9,699
Total amount of fees paid to insurance company	USD $809
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSP INC INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $66,718
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,857
Insurance broker organization code?	3
Amount paid for insurance broker fees	608
Additional information about fees paid to insurance broker	FEES
Insurance broker name	LOUIS ASCANIO

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1026182

Policy instance

Insurance contract or identification number	1026182
Number of Individuals Covered	164
Insurance policy start date	2014-04-01
Insurance policy end date	2015-03-31
Total amount of commissions paid to insurance broker	USD $5,583
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $55,539
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,583
Insurance broker organization code?	3
Insurance broker name	COLTON GROOM BENEFIT ADVISORS LLC

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1026182

Policy instance

Insurance contract or identification number	1026182
Number of Individuals Covered	164
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $5,376
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $53,252
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,376
Insurance broker organization code?	3
Insurance broker name	COLTON GROOM BENEFIT ADVISORS LLC

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

LIF/LTD30640

Policy instance

Insurance contract or identification number	LIF/LTD30640
Number of Individuals Covered	132
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $11,346
Total amount of fees paid to insurance company	USD $195
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $143,067
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,346
Insurance broker organization code?	3
Amount paid for insurance broker fees	195
Insurance broker name	MEDICAL GROUP INSURANCE SERVICES

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7531411

Policy instance

Insurance contract or identification number	E7531411
Number of Individuals Covered	57
Insurance policy start date	2013-04-01
Insurance policy end date	2014-03-31
Total amount of commissions paid to insurance broker	USD $9,561
Total amount of fees paid to insurance company	USD $434
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSP INC INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $65,200
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,984
Insurance broker organization code?	3
Amount paid for insurance broker fees	134
Insurance broker name	WILLARD STOCKTON HILL

J ALLAN HALL AND ASSOCIATES (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

SAJAH1006010114

Policy instance

Insurance contract or identification number	SAJAH1006010114
Number of Individuals Covered	105
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $17,261
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $112,999
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,987
Insurance broker organization code?	3
Insurance broker name	INTEGRA BENEFIT ADVISORS

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7531411

Policy instance

Insurance contract or identification number	E7531411
Number of Individuals Covered	62
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $10,288
Total amount of fees paid to insurance company	USD $569
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSP INC INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $63,390
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,027
Insurance broker organization code?	3
Amount paid for insurance broker fees	365
Insurance broker name	DAVID WAYNE JORDAN

PRINCIPAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61271 )

Policy contract number

1026182

Policy instance

Insurance contract or identification number	1026182
Number of Individuals Covered	184
Insurance policy start date	2012-04-01
Insurance policy end date	2013-03-31
Total amount of commissions paid to insurance broker	USD $5,992
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $60,362
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,992
Insurance broker name	COLTON GROOM BENEFIT ADVISORS LLC

J ALLAN HALL AND ASSOCIATES (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

LL-0030-010111

Policy instance

Insurance contract or identification number	LL-0030-010111
Number of Individuals Covered	110
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $16,918
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $96,566
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $11,743
Insurance broker organization code?	5
Insurance broker name	INTEGRA BENEFIT ADVISORS

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

LIF/LTD30640

Policy instance

Insurance contract or identification number	LIF/LTD30640
Number of Individuals Covered	161
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $5,329
Total amount of fees paid to insurance company	USD $165
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $67,624
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,329
Amount paid for insurance broker fees	165
Insurance broker organization code?	3
Insurance broker name	COLTON GROOM BENEFIT ADVISORS LLC

J ALLAN HALL AND ASSOCIATES (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

LL-0030-010111

Policy instance

Insurance contract or identification number	LL-0030-010111
Number of Individuals Covered	107
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $14,021
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $97,531
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

F8435

Policy instance

Insurance contract or identification number	F8435
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

LIF/LTD30640

Policy instance

Insurance contract or identification number	LIF/LTD30640
Number of Individuals Covered	134
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $5,538
Total amount of fees paid to insurance company	USD $180
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $70,294
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7531411

Policy instance

Insurance contract or identification number	E7531411
Number of Individuals Covered	57
Insurance policy start date	2011-04-01
Insurance policy end date	2012-03-31
Total amount of commissions paid to insurance broker	USD $8,032
Total amount of fees paid to insurance company	USD $278
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSP INC INSURANCE
Welfare Benefit Premiums Paid to Carrier	USD $59,188
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE AND HEALTH INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 80926 )

Policy contract number

048-7932-00

Policy instance

Insurance contract or identification number	048-7932-00
Number of Individuals Covered	90
Insurance policy start date	2011-04-01
Insurance policy end date	2012-04-01
Total amount of commissions paid to insurance broker	USD $3,353
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $56,839
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

F8435

Policy instance

Insurance contract or identification number	F8435
Number of Individuals Covered	113
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $5,851
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Dental Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $73,666
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,851
Insurance broker organization code?	3
Insurance broker name	INCOME & CAPITAL ASSOCIATES OF ASHE

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

LIF/LTD30640

Policy instance

Insurance contract or identification number	LIF/LTD30640
Number of Individuals Covered	130
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $4,979
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $63,334
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,979
Insurance broker organization code?	3
Insurance broker name	COLTON GROOME

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E7531411

Policy instance

Insurance contract or identification number	E7531411
Number of Individuals Covered	63
Insurance policy start date	2010-04-01
Insurance policy end date	2011-03-31
Total amount of commissions paid to insurance broker	USD $13,694
Total amount of fees paid to insurance company	USD $781
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	CANCER, HOSP INC INSURANCE
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,477
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	ANNA BOONE ROGERS

J ALLAN HALL AND ASSOCIATES (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

LL-0030-010111

Policy instance

Insurance contract or identification number	LL-0030-010111
Number of Individuals Covered	116
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $10,371
Total amount of fees paid to insurance company	USD $0
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Welfare Benefit Premiums Paid to Carrier	USD $106,126
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,607
Insurance broker organization code?	3
Insurance broker name	INTEGRA BMS

Potentially related plans

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Company Name:	BLUE RIDGE BONE & JOINT CLINIC, P.A
Employer identification number (EIN):	560951119
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)