401k Plan data: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN plan

EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 401k Plan overview

Plan Name	EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN
Plan identification number	502

EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY 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 Death benefits (include travel accident but not life insurance) Other welfare benefit cover

401k Sponsoring company profile

EYE SPECIALISTS OF MID-FLORIDA P.A. has sponsored the creation of one or more 401k plans.

Company Name: EYE SPECIALISTS OF MID-FLORIDA P.A.

Employer identification number (EIN): 591268885

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

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2016-10-01 DANIEL W. WELCH
502 2015-10-01 DANIEL W. WELCH
502 2014-10-01
502 2013-10-01
502 2012-10-01 DAVID LOEWY
502 2011-10-01 DANIEL WELCH
502 2009-10-01 DANIEL WELCH

Plan Statistics for EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN

401k plan membership statisitcs for EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN

Measure Date Value
2016: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2016 401k membership
Total participants, beginning-of-year 2016-10-01 150
Total number of active participants reported on line 7a of the Form 5500 2016-10-01 175
Number of retired or separated participants receiving benefits 2016-10-01 3
Number of other retired or separated participants entitled to future benefits 2016-10-01 0
Total of all active and inactive participants 2016-10-01 178
2015: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2015 401k membership
Total participants, beginning-of-year 2015-10-01 148
Total number of active participants reported on line 7a of the Form 5500 2015-10-01 150
Number of retired or separated participants receiving benefits 2015-10-01 2
Number of other retired or separated participants entitled to future benefits 2015-10-01 0
Total of all active and inactive participants 2015-10-01 152
2014: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2014 401k membership
Total participants, beginning-of-year 2014-10-01 139
Total number of active participants reported on line 7a of the Form 5500 2014-10-01 148
Total of all active and inactive participants 2014-10-01 148
2013: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2013 401k membership
Total participants, beginning-of-year 2013-10-01 127
Total number of active participants reported on line 7a of the Form 5500 2013-10-01 139
Total of all active and inactive participants 2013-10-01 139
2012: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2012 401k membership
Total participants, beginning-of-year 2012-10-01 123
Total number of active participants reported on line 7a of the Form 5500 2012-10-01 127
Total of all active and inactive participants 2012-10-01 127
2011: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2011 401k membership
Total participants, beginning-of-year 2011-10-01 124
Total number of active participants reported on line 7a of the Form 5500 2011-10-01 123
Total of all active and inactive participants 2011-10-01 123
2009: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2009 401k membership
Total participants, beginning-of-year 2009-10-01 155
Total number of active participants reported on line 7a of the Form 5500 2009-10-01 152
Total of all active and inactive participants 2009-10-01 152

Measure	Date	Value
2016: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2016 401k membership
Total participants, beginning-of-year	2016-10-01	150
Total number of active participants reported on line 7a of the Form 5500	2016-10-01	175
Number of retired or separated participants receiving benefits	2016-10-01	3
Number of other retired or separated participants entitled to future benefits	2016-10-01	0
Total of all active and inactive participants	2016-10-01	178
2015: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2015 401k membership
Total participants, beginning-of-year	2015-10-01	148
Total number of active participants reported on line 7a of the Form 5500	2015-10-01	150
Number of retired or separated participants receiving benefits	2015-10-01	2
Number of other retired or separated participants entitled to future benefits	2015-10-01	0
Total of all active and inactive participants	2015-10-01	152
2014: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2014 401k membership
Total participants, beginning-of-year	2014-10-01	139
Total number of active participants reported on line 7a of the Form 5500	2014-10-01	148
Total of all active and inactive participants	2014-10-01	148
2013: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2013 401k membership
Total participants, beginning-of-year	2013-10-01	127
Total number of active participants reported on line 7a of the Form 5500	2013-10-01	139
Total of all active and inactive participants	2013-10-01	139
2012: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2012 401k membership
Total participants, beginning-of-year	2012-10-01	123
Total number of active participants reported on line 7a of the Form 5500	2012-10-01	127
Total of all active and inactive participants	2012-10-01	127
2011: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2011 401k membership
Total participants, beginning-of-year	2011-10-01	124
Total number of active participants reported on line 7a of the Form 5500	2011-10-01	123
Total of all active and inactive participants	2011-10-01	123
2009: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2009 401k membership
Total participants, beginning-of-year	2009-10-01	155
Total number of active participants reported on line 7a of the Form 5500	2009-10-01	152
Total of all active and inactive participants	2009-10-01	152

Financial Data on EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN

Measure	Date	Value
2017 : EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2017 401k financial data
Total income from all sources	2017-09-30	$0
Total plan assets at end of year	2017-09-30	$0
Total plan assets at beginning of year	2017-09-30	$0
Net plan assets at end of year (total assets less liabilities)	2017-09-30	$0
Net plan assets at beginning of year (total assets less liabilities)	2017-09-30	$0

Form 5500 Responses for EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN

2016: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2016 form 5500 responses
2016-10-01	Type of plan entity	Single employer plan
2016-10-01	Plan funding arrangement – Insurance	Yes
2016-10-01	Plan benefit arrangement – Insurance	Yes
2015: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2015 form 5500 responses
2015-10-01	Type of plan entity	Single employer plan
2015-10-01	Submission has been amended	No
2015-10-01	This submission is the final filing	No
2015-10-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-10-01	Plan is a collectively bargained plan	No
2015-10-01	Plan funding arrangement – Insurance	Yes
2015-10-01	Plan benefit arrangement – Insurance	Yes
2014: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2014 form 5500 responses
2014-10-01	Type of plan entity	Single employer plan
2014-10-01	Plan funding arrangement – Insurance	Yes
2014-10-01	Plan benefit arrangement – Insurance	Yes
2013: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2013 form 5500 responses
2013-10-01	Type of plan entity	Single employer plan
2013-10-01	Plan funding arrangement – Insurance	Yes
2013-10-01	Plan benefit arrangement – Insurance	Yes
2012: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2012 form 5500 responses
2012-10-01	Type of plan entity	Single employer plan
2012-10-01	Plan funding arrangement – Insurance	Yes
2012-10-01	Plan benefit arrangement – Insurance	Yes
2011: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2011 form 5500 responses
2011-10-01	Type of plan entity	Single employer plan
2011-10-01	Plan funding arrangement – Insurance	Yes
2011-10-01	Plan benefit arrangement – Insurance	Yes
2009: EYE SPECIALISTS OF MID-FLORIDA P.A. EMPLOYEE ANCILLARY PLAN 2009 form 5500 responses
2009-10-01	Type of plan entity	Single employer plan
2009-10-01	This submission is the final filing	No
2009-10-01	Plan funding arrangement – Insurance	Yes
2009-10-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

649865

Policy instance

Insurance contract or identification number	649865
Number of Individuals Covered	57
Insurance policy start date	2014-09-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $1,734
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 $47,965
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,332
Insurance broker organization code?	3
Insurance broker name	ALLTRUST INSURANCE

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

588295

Policy instance

Insurance contract or identification number	588295
Number of Individuals Covered	148
Insurance policy start date	2014-09-01
Insurance policy end date	2015-09-01
Total amount of commissions paid to insurance broker	USD $8,323
Total amount of fees paid to insurance company	USD $440
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
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $87,267
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,726
Amount paid for insurance broker fees	440
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	ALLTRUST INSURANCE

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

588197

Policy instance

Insurance contract or identification number	588197
Number of Individuals Covered	49
Insurance policy start date	2014-09-01
Insurance policy end date	2015-09-01
Total amount of commissions paid to insurance broker	USD $1,986
Total amount of fees paid to insurance company	USD $67
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	LIFESTYLE ADD & LIFE
Welfare Benefit Premiums Paid to Carrier	USD $13,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,331
Amount paid for insurance broker fees	67
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	ALLTRUST INSURANCE

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

69540

Policy instance

Insurance contract or identification number	69540
Number of Individuals Covered	90
Insurance policy start date	2014-09-01
Insurance policy end date	2015-04-30
Total amount of commissions paid to insurance broker	USD $18,809
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
Health 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 $18,809
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES USA

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

69540

Policy instance

Insurance contract or identification number	69540
Number of Individuals Covered	92
Insurance policy start date	2015-05-01
Insurance policy end date	2015-08-31
Total amount of commissions paid to insurance broker	USD $8,581
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
Health 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 $8,581
Insurance broker organization code?	3
Insurance broker name	ALLTRUST INSURANCE

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

588295

Policy instance

Insurance contract or identification number	588295
Number of Individuals Covered	139
Insurance policy start date	2013-09-01
Insurance policy end date	2014-09-01
Total amount of commissions paid to insurance broker	USD $7,784
Total amount of fees paid to insurance company	USD $624
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
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $83,139
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $7,784
Amount paid for insurance broker fees	624
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SVCS USA, INC

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

69540

Policy instance

Insurance contract or identification number	69540
Number of Individuals Covered	99
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $27,107
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
Health 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 $27,107
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INSURANCE SERVICES US

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

649865

Policy instance

Insurance contract or identification number	649865
Number of Individuals Covered	55
Insurance policy start date	2013-09-01
Insurance policy end date	2014-08-31
Total amount of commissions paid to insurance broker	USD $1,595
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 $40,989
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,595
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SVCS USA INC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

588197

Policy instance

Insurance contract or identification number	588197
Number of Individuals Covered	40
Insurance policy start date	2013-09-01
Insurance policy end date	2014-09-01
Total amount of commissions paid to insurance broker	USD $1,764
Total amount of fees paid to insurance company	USD $88
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	LIFESTYLE ADD & LIFE
Welfare Benefit Premiums Paid to Carrier	USD $11,755
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,879
Amount paid for insurance broker fees	94
Additional information about fees paid to insurance broker	OTHER
Insurance broker organization code?	3
Insurance broker name	M E WILSON COMPANY, INC.

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

588295

Policy instance

Insurance contract or identification number	588295
Number of Individuals Covered	127
Insurance policy start date	2012-09-01
Insurance policy end date	2013-09-01
Total amount of commissions paid to insurance broker	USD $7,527
Total amount of fees paid to insurance company	USD $601
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
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $80,119
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,950
Amount paid for insurance broker fees	550
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMMISSION
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SVCS USA INC

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

649865

Policy instance

Insurance contract or identification number	649865
Number of Individuals Covered	50
Insurance policy start date	2012-09-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $1,736
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 $1,737
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,393
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO INS SVCS USA INC

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

69540

Policy instance

Insurance contract or identification number	69540
Number of Individuals Covered	92
Insurance policy start date	2012-09-01
Insurance policy end date	2013-08-31
Total amount of commissions paid to insurance broker	USD $25,474
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
Health 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 $25,474
Insurance broker organization code?	3
Insurance broker name	LIONS SHARE HOLDING, INC

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

588197

Policy instance

Insurance contract or identification number	588197
Number of Individuals Covered	39
Insurance policy start date	2012-09-01
Insurance policy end date	2013-09-01
Total amount of commissions paid to insurance broker	USD $1,439
Total amount of fees paid to insurance company	USD $72
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	LIFESTYLE ADD & LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,596
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,439
Amount paid for insurance broker fees	72
Additional information about fees paid to insurance broker	SUPPLEMENTAL COMMISSION
Insurance broker organization code?	3
Insurance broker name	M E WILSON COMPANY, INC.

FLORIDA COMBINED LIFE INSURANCE COMPANY, INC. (National Association of Insurance Commissioners NAIC id number: 76031 )

Policy contract number

15E0681

Policy instance

Insurance contract or identification number	15E0681
Number of Individuals Covered	55
Insurance policy start date	2012-01-01
Insurance policy end date	2012-08-31
Total amount of commissions paid to insurance broker	USD $1,641
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 $20,933
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

69540

Policy instance

Insurance contract or identification number	69540
Number of Individuals Covered	95
Insurance policy start date	2011-09-01
Insurance policy end date	2012-08-31
Total amount of commissions paid to insurance broker	USD $26,531
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
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

588197

Policy instance

Insurance contract or identification number	588197
Number of Individuals Covered	33
Insurance policy start date	2011-09-01
Insurance policy end date	2012-09-01
Total amount of commissions paid to insurance broker	USD $1,469
Total amount of fees paid to insurance company	USD $21
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	LIFESTYLE ADD & LIFE
Welfare Benefit Premiums Paid to Carrier	USD $9,791
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

588295

Policy instance

Insurance contract or identification number	588295
Number of Individuals Covered	123
Insurance policy start date	2011-09-01
Insurance policy end date	2012-09-01
Total amount of commissions paid to insurance broker	USD $7,952
Total amount of fees paid to insurance company	USD $204
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
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $85,138
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

649865

Policy instance

Insurance contract or identification number	649865
Number of Individuals Covered	55
Insurance policy start date	2011-09-01
Insurance policy end date	2012-09-30
Total amount of commissions paid to insurance broker	USD $291
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 $2,913
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF FLORIDA (National Association of Insurance Commissioners NAIC id number: 98167 )

Policy contract number

69540

Policy instance

Insurance contract or identification number	69540
Number of Individuals Covered	97
Insurance policy start date	2010-09-01
Insurance policy end date	2011-08-31
Total amount of commissions paid to insurance broker	USD $26,401
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
Health Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

588197

Policy instance

Insurance contract or identification number	588197
Number of Individuals Covered	39
Insurance policy start date	2010-09-01
Insurance policy end date	2011-09-01
Total amount of commissions paid to insurance broker	USD $1,266
Total amount of fees paid to insurance company	USD $21
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Other welfare benefits provided	LIFESTYLE ADD & LIFE
Welfare Benefit Premiums Paid to Carrier	USD $8,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

588295

Policy instance

Insurance contract or identification number	588295
Number of Individuals Covered	124
Insurance policy start date	2010-09-01
Insurance policy end date	2011-09-01
Total amount of commissions paid to insurance broker	USD $7,310
Total amount of fees paid to insurance company	USD $196
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
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	AD&D
Welfare Benefit Premiums Paid to Carrier	USD $77,961
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

00450584

Policy instance

Insurance contract or identification number	00450584
Number of Individuals Covered	55
Insurance policy start date	2010-09-01
Insurance policy end date	2011-08-31
Total amount of commissions paid to insurance broker	USD $2,326
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 $31,210
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	EYE SPECIALISTS OF MID-FLORIDA P.A.
Employer identification number (EIN):	591268885
NAIC Classification:	621111
NAIC Description:	Offices of Physicians (except Mental Health Specialists)

Plan id#	Filing Submission Date	Name of Administrator
502	2016-10-01	DANIEL W. WELCH
502	2015-10-01	DANIEL W. WELCH
502	2014-10-01
502	2013-10-01
502	2012-10-01	DAVID LOEWY
502	2011-10-01	DANIEL WELCH
502	2009-10-01	DANIEL WELCH