401k Plan data: EMPLOYERS 401(K) ELITE RETIREMENT PLAN plan

EMPLOYERS 401(K) ELITE RETIREMENT PLAN 401k Plan overview

Plan Name	EMPLOYERS 401(K) ELITE RETIREMENT PLAN
Plan identification number	001

EMPLOYERS 401(K) ELITE RETIREMENT PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.
Plan sponsor(s) is (are) a member(s) of a controlled group (Code sections 414(b), (c), or (m)).

401k Sponsoring company profile

BIG BRAN has sponsored the creation of one or more 401k plans.

Company Name: BIG BRAN

Employer identification number (EIN): 561274190

NAIC Classification: 722513
NAIC Description: Limited-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYERS 401(K) ELITE RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2015-01-01 BETTY CALDWELL
001 2014-01-01 BETTY CALDWELL
001 2013-01-01 JILL M. WILLIAMS
001 2012-01-01 HUGH E. BIGHAM
001 2011-01-01 HUGH E. BIGHAM
001 2009-01-01 HUGH E. BIGHAM HUGH E. BIGHAM 2010-09-17

Plan id#	Filing Submission Date	Name of Administrator	Name of Company Sponsor	Date Sponsor Signed
001	2015-01-01	BETTY CALDWELL
001	2014-01-01	BETTY CALDWELL
001	2013-01-01	JILL M. WILLIAMS
001	2012-01-01	HUGH E. BIGHAM
001	2011-01-01	HUGH E. BIGHAM
001	2009-01-01	HUGH E. BIGHAM	HUGH E. BIGHAM	2010-09-17

Plan Statistics for EMPLOYERS 401(K) ELITE RETIREMENT PLAN

401k plan membership statisitcs for EMPLOYERS 401(K) ELITE RETIREMENT PLAN

Measure Date Value
2015: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 258
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 222
Number of retired or separated participants receiving benefits 2015-01-01 0
Number of other retired or separated participants entitled to future benefits 2015-01-01 6
Total of all active and inactive participants 2015-01-01 228
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 228
Number of participants with account balances 2015-01-01 60
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 2
2014: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 274
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 224
Number of retired or separated participants receiving benefits 2014-01-01 0
Number of other retired or separated participants entitled to future benefits 2014-01-01 5
Total of all active and inactive participants 2014-01-01 229
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2014-01-01 0
Total participants 2014-01-01 229
Number of participants with account balances 2014-01-01 67
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 1
2013: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2013 401k membership
Total participants, beginning-of-year 2013-01-01 271
Total number of active participants reported on line 7a of the Form 5500 2013-01-01 239
Number of retired or separated participants receiving benefits 2013-01-01 0
Number of other retired or separated participants entitled to future benefits 2013-01-01 15
Total of all active and inactive participants 2013-01-01 254
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2013-01-01 0
Total participants 2013-01-01 254
Number of participants with account balances 2013-01-01 81
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2013-01-01 1
2012: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year 2012-01-01 271
Total number of active participants reported on line 7a of the Form 5500 2012-01-01 239
Number of retired or separated participants receiving benefits 2012-01-01 2
Number of other retired or separated participants entitled to future benefits 2012-01-01 15
Total of all active and inactive participants 2012-01-01 256
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2012-01-01 0
Total participants 2012-01-01 256
Number of participants with account balances 2012-01-01 85
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2012-01-01 3
2011: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-01-01 267
Total number of active participants reported on line 7a of the Form 5500 2011-01-01 239
Number of retired or separated participants receiving benefits 2011-01-01 5
Number of other retired or separated participants entitled to future benefits 2011-01-01 14
Total of all active and inactive participants 2011-01-01 258
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-01-01 0
Total participants 2011-01-01 258
Number of participants with account balances 2011-01-01 97
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2011-01-01 1
2009: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2009 401k membership
Total participants, beginning-of-year 2009-01-01 245
Total number of active participants reported on line 7a of the Form 5500 2009-01-01 239
Number of retired or separated participants receiving benefits 2009-01-01 3
Number of other retired or separated participants entitled to future benefits 2009-01-01 12
Total of all active and inactive participants 2009-01-01 254
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2009-01-01 0
Total participants 2009-01-01 254
Number of participants with account balances 2009-01-01 90
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2009-01-01 1

Measure	Date	Value
2015: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	258
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	222
Number of retired or separated participants receiving benefits	2015-01-01	0
Number of other retired or separated participants entitled to future benefits	2015-01-01	6
Total of all active and inactive participants	2015-01-01	228
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	228
Number of participants with account balances	2015-01-01	60
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	2
2014: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	274
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	224
Number of retired or separated participants receiving benefits	2014-01-01	0
Number of other retired or separated participants entitled to future benefits	2014-01-01	5
Total of all active and inactive participants	2014-01-01	229
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2014-01-01	0
Total participants	2014-01-01	229
Number of participants with account balances	2014-01-01	67
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	1
2013: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2013 401k membership
Total participants, beginning-of-year	2013-01-01	271
Total number of active participants reported on line 7a of the Form 5500	2013-01-01	239
Number of retired or separated participants receiving benefits	2013-01-01	0
Number of other retired or separated participants entitled to future benefits	2013-01-01	15
Total of all active and inactive participants	2013-01-01	254
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2013-01-01	0
Total participants	2013-01-01	254
Number of participants with account balances	2013-01-01	81
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2013-01-01	1
2012: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2012 401k membership
Total participants, beginning-of-year	2012-01-01	271
Total number of active participants reported on line 7a of the Form 5500	2012-01-01	239
Number of retired or separated participants receiving benefits	2012-01-01	2
Number of other retired or separated participants entitled to future benefits	2012-01-01	15
Total of all active and inactive participants	2012-01-01	256
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2012-01-01	0
Total participants	2012-01-01	256
Number of participants with account balances	2012-01-01	85
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2012-01-01	3
2011: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-01-01	267
Total number of active participants reported on line 7a of the Form 5500	2011-01-01	239
Number of retired or separated participants receiving benefits	2011-01-01	5
Number of other retired or separated participants entitled to future benefits	2011-01-01	14
Total of all active and inactive participants	2011-01-01	258
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-01-01	0
Total participants	2011-01-01	258
Number of participants with account balances	2011-01-01	97
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2011-01-01	1
2009: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2009 401k membership
Total participants, beginning-of-year	2009-01-01	245
Total number of active participants reported on line 7a of the Form 5500	2009-01-01	239
Number of retired or separated participants receiving benefits	2009-01-01	3
Number of other retired or separated participants entitled to future benefits	2009-01-01	12
Total of all active and inactive participants	2009-01-01	254
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2009-01-01	0
Total participants	2009-01-01	254
Number of participants with account balances	2009-01-01	90
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2009-01-01	1

Financial Data on EMPLOYERS 401(K) ELITE RETIREMENT PLAN

Measure	Date	Value
2015 : EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets	2015-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2015-12-31	$0
Total income from all sources (including contributions)	2015-12-31	$87,637
Total loss/gain on sale of assets	2015-12-31	$0
Total of all expenses incurred	2015-12-31	$245,204
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$238,824
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$107,672
Value of total assets at end of year	2015-12-31	$1,386,923
Value of total assets at beginning of year	2015-12-31	$1,544,490
Total of administrative expenses incurred including professional, contract, advisory and management fees	2015-12-31	$6,380
Total interest from all sources	2015-12-31	$1,793
Total dividends received (eg from common stock, registered investment company shares)	2015-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2015-12-31	No
Was this plan covered by a fidelity bond	2015-12-31	Yes
Value of fidelity bond cover	2015-12-31	$100,000
If this is an individual account plan, was there a blackout period	2015-12-31	Yes
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2015-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2015-12-31	No
Contributions received from participants	2015-12-31	$95,305
Participant contributions at end of year	2015-12-31	$34,096
Participant contributions at beginning of year	2015-12-31	$45,905
Participant contributions at end of year	2015-12-31	$2,968
Participant contributions at beginning of year	2015-12-31	$0
Total non interest bearing cash at end of year	2015-12-31	$262
Total non interest bearing cash at beginning of year	2015-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2015-12-31	No
Value of net income/loss	2015-12-31	$-157,567
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$1,386,923
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$1,544,490
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2015-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2015-12-31	No
Were any leases to which the plan was party in default or uncollectible	2015-12-31	No
Value of interest in pooled separate accounts at end of year	2015-12-31	$1,279,591
Value of interest in pooled separate accounts at beginning of year	2015-12-31	$1,427,021
Interest on participant loans	2015-12-31	$1,793
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2015-12-31	$56,894
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2015-12-31	$58,086
Net investment gain/loss from pooled separate accounts	2015-12-31	$-21,828
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2015-12-31	No
Was there a failure to transmit to the plan any participant contributions	2015-12-31	No
Has the plan failed to provide any benefit when due under the plan	2015-12-31	No
Contributions received in cash from employer	2015-12-31	$12,367
Employer contributions (assets) at end of year	2015-12-31	$13,112
Employer contributions (assets) at beginning of year	2015-12-31	$13,478
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$238,824
Contract administrator fees	2015-12-31	$6,380
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2015-12-31	Yes
Did the plan have assets held for investment	2015-12-31	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	2015-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2015-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2015-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2015-12-31	Disclaimer
Accountancy firm name	2015-12-31	MCCANNON ROGERS DRISCOLL & ASSOC
Accountancy firm EIN	2015-12-31	561056216
2014 : EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2014 401k financial data
Total unrealized appreciation/depreciation of assets	2014-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2014-12-31	$0
Total income from all sources (including contributions)	2014-12-31	$191,904
Total loss/gain on sale of assets	2014-12-31	$0
Total of all expenses incurred	2014-12-31	$31,069
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$27,060
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$96,151
Value of total assets at end of year	2014-12-31	$1,544,490
Value of total assets at beginning of year	2014-12-31	$1,383,655
Total of administrative expenses incurred including professional, contract, advisory and management fees	2014-12-31	$4,009
Total interest from all sources	2014-12-31	$1,456
Total dividends received (eg from common stock, registered investment company shares)	2014-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2014-12-31	No
Was this plan covered by a fidelity bond	2014-12-31	Yes
Value of fidelity bond cover	2014-12-31	$100,000
If this is an individual account plan, was there a blackout period	2014-12-31	Yes
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2014-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2014-12-31	No
Contributions received from participants	2014-12-31	$82,504
Participant contributions at end of year	2014-12-31	$45,905
Participant contributions at beginning of year	2014-12-31	$18,693
Participant contributions at end of year	2014-12-31	$0
Participant contributions at beginning of year	2014-12-31	$0
Administrative expenses (other) incurred	2014-12-31	$-100
Total non interest bearing cash at end of year	2014-12-31	$0
Total non interest bearing cash at beginning of year	2014-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2014-12-31	No
Income. Non cash contributions	2014-12-31	$100
Value of net income/loss	2014-12-31	$160,835
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$1,544,490
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$1,383,655
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2014-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2014-12-31	No
Were any leases to which the plan was party in default or uncollectible	2014-12-31	No
Value of interest in pooled separate accounts at end of year	2014-12-31	$1,427,021
Value of interest in pooled separate accounts at beginning of year	2014-12-31	$1,294,750
Interest on participant loans	2014-12-31	$1,456
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2014-12-31	$58,086
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2014-12-31	$56,977
Net investment gain/loss from pooled separate accounts	2014-12-31	$94,297
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2014-12-31	No
Was there a failure to transmit to the plan any participant contributions	2014-12-31	No
Has the plan failed to provide any benefit when due under the plan	2014-12-31	No
Contributions received in cash from employer	2014-12-31	$13,547
Employer contributions (assets) at end of year	2014-12-31	$13,478
Employer contributions (assets) at beginning of year	2014-12-31	$13,235
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$27,060
Contract administrator fees	2014-12-31	$4,109
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2014-12-31	Yes
Did the plan have assets held for investment	2014-12-31	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	2014-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2014-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2014-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2014-12-31	Disclaimer
Accountancy firm name	2014-12-31	MCCANNON ROGERS DRISCOLL & ASSOC
Accountancy firm EIN	2014-12-31	561056216
2013 : EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2013 401k financial data
Total unrealized appreciation/depreciation of assets	2013-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2013-12-31	$0
Total income from all sources (including contributions)	2013-12-31	$297,989
Total loss/gain on sale of assets	2013-12-31	$0
Total of all expenses incurred	2013-12-31	$9,070
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2013-12-31	$5,231
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2013-12-31	$94,417
Value of total assets at end of year	2013-12-31	$1,383,655
Value of total assets at beginning of year	2013-12-31	$1,094,736
Total of administrative expenses incurred including professional, contract, advisory and management fees	2013-12-31	$3,839
Total interest from all sources	2013-12-31	$982
Total dividends received (eg from common stock, registered investment company shares)	2013-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2013-12-31	No
Was this plan covered by a fidelity bond	2013-12-31	Yes
Value of fidelity bond cover	2013-12-31	$100,000
If this is an individual account plan, was there a blackout period	2013-12-31	Yes
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2013-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2013-12-31	No
Contributions received from participants	2013-12-31	$81,182
Participant contributions at end of year	2013-12-31	$18,693
Participant contributions at beginning of year	2013-12-31	$0
Other income not declared elsewhere	2013-12-31	$11,284
Administrative expenses (other) incurred	2013-12-31	$1,233
Total non interest bearing cash at end of year	2013-12-31	$0
Total non interest bearing cash at beginning of year	2013-12-31	$98
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2013-12-31	No
Value of net income/loss	2013-12-31	$288,919
Value of net assets at end of year (total assets less liabilities)	2013-12-31	$1,383,655
Value of net assets at beginning of year (total assets less liabilities)	2013-12-31	$1,094,736
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2013-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2013-12-31	No
Were any leases to which the plan was party in default or uncollectible	2013-12-31	No
Value of interest in pooled separate accounts at end of year	2013-12-31	$1,294,750
Value of interest in pooled separate accounts at beginning of year	2013-12-31	$1,094,638
Interest on participant loans	2013-12-31	$215
Interest earned on other investments	2013-12-31	$767
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2013-12-31	$56,977
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2013-12-31	$0
Net investment gain/loss from pooled separate accounts	2013-12-31	$191,306
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2013-12-31	No
Was there a failure to transmit to the plan any participant contributions	2013-12-31	No
Has the plan failed to provide any benefit when due under the plan	2013-12-31	No
Contributions received in cash from employer	2013-12-31	$13,235
Employer contributions (assets) at end of year	2013-12-31	$13,235
Employer contributions (assets) at beginning of year	2013-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2013-12-31	$5,231
Contract administrator fees	2013-12-31	$2,606
Was the provided the required notice or one of the exceptions to providing the black out period notice applied under 29 CFR 2520.101-3	2013-12-31	Yes
Did the plan have assets held for investment	2013-12-31	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	2013-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2013-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2013-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2013-12-31	Disclaimer
Accountancy firm name	2013-12-31	MCCANNON ROGERS DRISCOLL & ASSOC
Accountancy firm EIN	2013-12-31	561056216
2012 : EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2012 401k financial data
Total unrealized appreciation/depreciation of assets	2012-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2012-12-31	$0
Total income from all sources (including contributions)	2012-12-31	$215,447
Total loss/gain on sale of assets	2012-12-31	$0
Total of all expenses incurred	2012-12-31	$41,276
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2012-12-31	$27,644
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2012-12-31	$82,327
Value of total assets at end of year	2012-12-31	$1,094,736
Value of total assets at beginning of year	2012-12-31	$920,565
Total of administrative expenses incurred including professional, contract, advisory and management fees	2012-12-31	$13,632
Total interest from all sources	2012-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2012-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2012-12-31	No
Was this plan covered by a fidelity bond	2012-12-31	Yes
Value of fidelity bond cover	2012-12-31	$100,000
If this is an individual account plan, was there a blackout period	2012-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2012-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2012-12-31	No
Contributions received from participants	2012-12-31	$69,957
Total non interest bearing cash at end of year	2012-12-31	$98
Total non interest bearing cash at beginning of year	2012-12-31	$132
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2012-12-31	No
Value of net income/loss	2012-12-31	$174,171
Value of net assets at end of year (total assets less liabilities)	2012-12-31	$1,094,736
Value of net assets at beginning of year (total assets less liabilities)	2012-12-31	$920,565
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2012-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2012-12-31	No
Were any leases to which the plan was party in default or uncollectible	2012-12-31	No
Investment advisory and management fees	2012-12-31	$13,632
Value of interest in pooled separate accounts at end of year	2012-12-31	$1,094,638
Value of interest in pooled separate accounts at beginning of year	2012-12-31	$907,437
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2012-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2012-12-31	$12,996
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2012-12-31	$12,996
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2012-12-31	$133,120
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2012-12-31	No
Was there a failure to transmit to the plan any participant contributions	2012-12-31	No
Has the plan failed to provide any benefit when due under the plan	2012-12-31	No
Contributions received in cash from employer	2012-12-31	$12,370
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2012-12-31	$27,644
Did the plan have assets held for investment	2012-12-31	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	2012-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2012-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2012-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2012-12-31	Disclaimer
Accountancy firm name	2012-12-31	MCCANNON ROGERS DRISCOLL & ASSOC
Accountancy firm EIN	2012-12-31	561056216
2011 : EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2011 401k financial data
Total unrealized appreciation/depreciation of assets	2011-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2011-12-31	$0
Total income from all sources (including contributions)	2011-12-31	$54,950
Total loss/gain on sale of assets	2011-12-31	$0
Total of all expenses incurred	2011-12-31	$66,598
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2011-12-31	$53,848
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2011-12-31	$87,039
Value of total assets at end of year	2011-12-31	$920,565
Value of total assets at beginning of year	2011-12-31	$932,213
Total of administrative expenses incurred including professional, contract, advisory and management fees	2011-12-31	$12,750
Total interest from all sources	2011-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2011-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2011-12-31	No
Was this plan covered by a fidelity bond	2011-12-31	Yes
Value of fidelity bond cover	2011-12-31	$10,000
If this is an individual account plan, was there a blackout period	2011-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2011-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2011-12-31	No
Contributions received from participants	2011-12-31	$75,719
Income. Received or receivable in cash from other sources (including rollovers)	2011-12-31	$132
Total non interest bearing cash at end of year	2011-12-31	$132
Total non interest bearing cash at beginning of year	2011-12-31	$75
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2011-12-31	No
Value of net income/loss	2011-12-31	$-11,648
Value of net assets at end of year (total assets less liabilities)	2011-12-31	$920,565
Value of net assets at beginning of year (total assets less liabilities)	2011-12-31	$932,213
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2011-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2011-12-31	No
Were any leases to which the plan was party in default or uncollectible	2011-12-31	No
Investment advisory and management fees	2011-12-31	$12,750
Value of interest in pooled separate accounts at end of year	2011-12-31	$907,437
Value of interest in pooled separate accounts at beginning of year	2011-12-31	$886,505
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2011-12-31	$12,996
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2011-12-31	$45,633
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2011-12-31	$45,633
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2011-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2011-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2011-12-31	$-32,089
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2011-12-31	No
Was there a failure to transmit to the plan any participant contributions	2011-12-31	No
Has the plan failed to provide any benefit when due under the plan	2011-12-31	No
Contributions received in cash from employer	2011-12-31	$11,188
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2011-12-31	$53,848
Did the plan have assets held for investment	2011-12-31	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	2011-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2011-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2011-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2011-12-31	Disclaimer
Accountancy firm name	2011-12-31	MCCANNON ROGERS DRISCOLL & ASSOC
Accountancy firm EIN	2011-12-31	561056216
2010 : EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2010 401k financial data
Total unrealized appreciation/depreciation of assets	2010-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2010-12-31	$625
Total income from all sources (including contributions)	2010-12-31	$196,866
Total loss/gain on sale of assets	2010-12-31	$0
Total of all expenses incurred	2010-12-31	$76,408
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2010-12-31	$64,472
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2010-12-31	$90,048
Value of total assets at end of year	2010-12-31	$932,213
Value of total assets at beginning of year	2010-12-31	$812,380
Total of administrative expenses incurred including professional, contract, advisory and management fees	2010-12-31	$11,936
Total interest from all sources	2010-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2010-12-31	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2010-12-31	No
Administrative expenses professional fees incurred	2010-12-31	$160
Was this plan covered by a fidelity bond	2010-12-31	Yes
Value of fidelity bond cover	2010-12-31	$100,000
If this is an individual account plan, was there a blackout period	2010-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2010-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2010-12-31	No
Contributions received from participants	2010-12-31	$78,614
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at end of year	2010-12-31	$0
Other liabilities (not benefit claims, operating payabales oe acquisition indebtedness) at beginning of year	2010-12-31	$625
Total non interest bearing cash at end of year	2010-12-31	$0
Total non interest bearing cash at beginning of year	2010-12-31	$625
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2010-12-31	No
Value of net income/loss	2010-12-31	$120,458
Value of net assets at end of year (total assets less liabilities)	2010-12-31	$932,213
Value of net assets at beginning of year (total assets less liabilities)	2010-12-31	$811,755
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2010-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2010-12-31	No
Were any leases to which the plan was party in default or uncollectible	2010-12-31	No
Value of interest in pooled separate accounts at end of year	2010-12-31	$932,213
Value of interest in pooled separate accounts at beginning of year	2010-12-31	$770,682
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2010-12-31	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2010-12-31	$41,073
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2010-12-31	$41,073
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2010-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2010-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2010-12-31	$106,818
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2010-12-31	No
Was there a failure to transmit to the plan any participant contributions	2010-12-31	No
Has the plan failed to provide any benefit when due under the plan	2010-12-31	No
Contributions received in cash from employer	2010-12-31	$11,434
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2010-12-31	$64,472
Contract administrator fees	2010-12-31	$11,776
Did the plan have assets held for investment	2010-12-31	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	2010-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2010-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2010-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2010-12-31	Disclaimer
Accountancy firm name	2010-12-31	MCCANNON ROGERS DRISCOLL & ASSOC
Accountancy firm EIN	2010-12-31	561056216
2009 : EMPLOYERS 401(K) ELITE RETIREMENT 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 EMPLOYERS 401(K) ELITE RETIREMENT PLAN

2015: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	Submission has been amended	No
2015-01-01	This submission is the final filing	No
2015-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-01-01	Plan is a collectively bargained plan	No
2015-01-01	Plan funding arrangement – Insurance	Yes
2015-01-01	Plan funding arrangement – Trust	Yes
2015-01-01	Plan benefit arrangement – Insurance	Yes
2015-01-01	Plan benefit arrangement - Trust	Yes
2014: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Submission has been amended	No
2014-01-01	This submission is the final filing	No
2014-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-01-01	Plan is a collectively bargained plan	No
2014-01-01	Plan funding arrangement – Insurance	Yes
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement – Insurance	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes
2013: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2013 form 5500 responses
2013-01-01	Type of plan entity	Single employer plan
2013-01-01	Submission has been amended	No
2013-01-01	This submission is the final filing	No
2013-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-01-01	Plan is a collectively bargained plan	No
2013-01-01	Plan funding arrangement – Insurance	Yes
2013-01-01	Plan funding arrangement – Trust	Yes
2013-01-01	Plan benefit arrangement – Insurance	Yes
2013-01-01	Plan benefit arrangement - Trust	Yes
2012: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2012 form 5500 responses
2012-01-01	Type of plan entity	Single employer plan
2012-01-01	Submission has been amended	No
2012-01-01	This submission is the final filing	No
2012-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-01-01	Plan is a collectively bargained plan	No
2012-01-01	Plan funding arrangement – Insurance	Yes
2012-01-01	Plan funding arrangement – Trust	Yes
2012-01-01	Plan benefit arrangement – Insurance	Yes
2012-01-01	Plan benefit arrangement - Trust	Yes
2011: EMPLOYERS 401(K) ELITE RETIREMENT PLAN 2011 form 5500 responses
2011-01-01	Type of plan entity	Single employer plan
2011-01-01	Submission has been amended	No
2011-01-01	This submission is the final filing	No
2011-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-01-01	Plan is a collectively bargained plan	No
2011-01-01	Plan funding arrangement – Insurance	Yes
2011-01-01	Plan funding arrangement – Trust	Yes
2011-01-01	Plan benefit arrangement – Insurance	Yes
2011-01-01	Plan benefit arrangement - Trust	Yes
2009: EMPLOYERS 401(K) ELITE RETIREMENT 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

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

E31 8331

Policy instance

Insurance contract or identification number	E31 8331
Number of Individuals Covered	60
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $6,036
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
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?	No
Commission paid to Insurance Broker	USD $6,036
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO ADV INS AGENCY

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

E31 8331

Policy instance

Insurance contract or identification number	E31 8331
Number of Individuals Covered	68
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,593
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
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?	No
Commission paid to Insurance Broker	USD $5,593
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO ADV INS AGENCY

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

21106

Policy instance

Insurance contract or identification number	21106
Number of Individuals Covered	0
Insurance policy start date	2013-01-01
Insurance policy end date	2013-02-19
Total amount of commissions paid to insurance broker	USD $1,389
Total amount of fees paid to insurance company	USD $46
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	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?	No
Commission paid to Insurance Broker	USD $1,389
Insurance broker organization code?	3
Amount paid for insurance broker fees	46
Additional information about fees paid to insurance broker	TPA COMPENSATION
Insurance broker name	PENTEGRA RETIREMENT SERVICES

AMERITAS LIFE INSURANCE CORP. (National Association of Insurance Commissioners NAIC id number: 61301 )

Policy contract number

E31 8331

Policy instance

Insurance contract or identification number	E31 8331
Number of Individuals Covered	81
Insurance policy start date	2013-01-01
Insurance policy end date	2013-12-31
Total amount of commissions paid to insurance broker	USD $4,025
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	Yes
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?	No
Commission paid to Insurance Broker	USD $4,025
Insurance broker organization code?	3
Insurance broker name	WELLS FARGO ADV INS AGY, LLC

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

21106

Policy instance

Insurance contract or identification number	21106
Number of Individuals Covered	94
Insurance policy start date	2012-01-01
Insurance policy end date	2012-12-31
Total amount of commissions paid to insurance broker	USD $7,579
Total amount of fees paid to insurance company	USD $507
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	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?	No
Commission paid to Insurance Broker	USD $7,579
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	ALLIANCE BENEFIT GROUP CAROLINAS

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

21106

Policy instance

Insurance contract or identification number	21106
Number of Individuals Covered	104
Insurance policy start date	2011-01-01
Insurance policy end date	2011-12-31
Total amount of commissions paid to insurance broker	USD $7,513
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	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?	No

JOHN HANCOCK LIFE INSURANCE COMPANY (U.S.A.) (National Association of Insurance Commissioners NAIC id number: 65838 )

Policy contract number

21106

Policy instance

Insurance contract or identification number	21106
Number of Individuals Covered	102
Insurance policy start date	2010-01-01
Insurance policy end date	2010-12-31
Total amount of commissions paid to insurance broker	USD $6,882
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	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?	No
Commission paid to Insurance Broker	USD $6,304
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	COMMISSIONS
Insurance broker organization code?	3
Insurance broker name	ALLIANCE BENEFIT GROUP CAROLINAS

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Company Name:	BIG BRAN
Employer identification number (EIN):	561274190
NAIC Classification:	722513
NAIC Description:	Limited-Service Restaurants