401k Plan data: R.W. BAKERS CO. LIFE AND DISABILITY PLAN plan

R.W. BAKERS CO. LIFE AND DISABILITY PLAN 401k Plan overview

Plan Name	R.W. BAKERS CO. LIFE AND DISABILITY PLAN
Plan identification number	507

R.W. BAKERS CO. LIFE AND DISABILITY PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Life insurance Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

EPI BREADS has sponsored the creation of one or more 401k plans.

Company Name: EPI BREADS

Employer identification number (EIN): 581591993

NAIC Classification: 311800
NAIC Description: Bakeries and Tortilla Manufacturing

Form 5500 Filing Information

Submission information for form 5500 for 401k plan R.W. BAKERS CO. LIFE AND DISABILITY PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
507 2015-01-01 JEFF BOHM

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
507	2015-01-01	JEFF BOHM

Plan Statistics for R.W. BAKERS CO. LIFE AND DISABILITY PLAN

401k plan membership statisitcs for R.W. BAKERS CO. LIFE AND DISABILITY PLAN

Measure Date Value
2015: R.W. BAKERS CO. LIFE AND DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 106
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 140
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 0
Total of all active and inactive participants 2015-01-01 140

Measure	Date	Value
2015: R.W. BAKERS CO. LIFE AND DISABILITY PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	106
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	140
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	0
Total of all active and inactive participants	2015-01-01	140

Form 5500 Responses for R.W. BAKERS CO. LIFE AND DISABILITY PLAN

2015: R.W. BAKERS CO. LIFE AND DISABILITY PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
2015-01-01	First time form 5500 has been submitted	Yes
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 benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

HARTFORD LIFE AND ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 70815 )

Policy contract number

851246G

Policy instance

Insurance contract or identification number	851246G
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 $1,387
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	Yes
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	AD&D
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $13,394
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,387
Amount paid for insurance broker fees	0
Additional information about fees paid to insurance broker	N/A
Insurance broker organization code?	3
Insurance broker name	FOX INSURANCE AGENCY INC.

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Company Name:	EPI BREADS
Employer identification number (EIN):	581591993
NAIC Classification:	311800
NAIC Description:	Bakeries and Tortilla Manufacturing