401k Plan data: BI-RITE MARKET 18TH ST. RETIREMENT PLAN plan

BI-RITE MARKET 18TH ST. RETIREMENT PLAN 401k Plan overview

Plan Name	BI-RITE MARKET 18TH ST. RETIREMENT PLAN
Plan identification number	001

BI-RITE MARKET 18TH ST. RETIREMENT PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Age/Service Weighted or new comparability or similar plan - Age/Service Weighted Plan: Allocations are based on age, service, or age and service. New comparability or similar plan: Allocations are based on participant classifications and a classification(s) consists entirely or predominantly of highly compensated employees; or the plan provides an additional allocation rate on compensation above a specified threshold, and the theshold or additional rate exceeds the maximum threshold or rate allowed under the permitted disparity rules of section 401(l).
Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
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.

401k Sponsoring company profile

BI-RITE MARKET INC. has sponsored the creation of one or more 401k plans.

Company Name: BI-RITE MARKET INC.

Employer identification number (EIN): 203183322

NAIC Classification: 445110
NAIC Description: Supermarkets and Other Grocery (except Convenience) Stores

Additional information about BI-RITE MARKET INC.

Jurisdiction of Incorporation: California Department of State

Incorporation Date: 2005-03-09

Company Identification Number: C2725944

Legal Registered Office Address: 3639 18th St

San Francisco
United States of America (USA)
94110

More information about BI-RITE MARKET INC.

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BI-RITE MARKET 18TH ST. RETIREMENT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2017-01-01 JEFFREY GRIFFIN
001 2016-01-01 JEFFREY GRIFFIN
001 2015-01-01 JEFFREY GRIFFIN
001 2014-01-01 PAULA BRANNON
001 2013-01-01 OSAMA MOGANNAM 2014-10-15
001 2012-01-01 OSAMA MOGANNAM 2013-10-14
001 2011-01-01 ALAN D. KRUEGER 2012-10-11
001 2010-01-01 ALAN D. KRUEGER 2011-10-10

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
001	2017-01-01	JEFFREY GRIFFIN
001	2016-01-01	JEFFREY GRIFFIN
001	2015-01-01	JEFFREY GRIFFIN
001	2014-01-01	PAULA BRANNON
001	2013-01-01	OSAMA MOGANNAM	2014-10-15
001	2012-01-01	OSAMA MOGANNAM	2013-10-14
001	2011-01-01	ALAN D. KRUEGER	2012-10-11
001	2010-01-01	ALAN D. KRUEGER	2011-10-10

Plan Statistics for BI-RITE MARKET 18TH ST. RETIREMENT PLAN

401k plan membership statisitcs for BI-RITE MARKET 18TH ST. RETIREMENT PLAN

Measure Date Value
2017: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 141
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 188
Number of retired or separated participants receiving benefits 2017-01-01 0
Number of other retired or separated participants entitled to future benefits 2017-01-01 144
Total of all active and inactive participants 2017-01-01 332
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2017-01-01 0
Total participants 2017-01-01 332
Number of participants with account balances 2017-01-01 289
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2017-01-01 18
2016: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 135
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 66
Number of retired or separated participants receiving benefits 2016-01-01 0
Number of other retired or separated participants entitled to future benefits 2016-01-01 75
Total of all active and inactive participants 2016-01-01 141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2016-01-01 0
Total participants 2016-01-01 141
Number of participants with account balances 2016-01-01 135
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2016-01-01 20
2015: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-01-01 123
Total number of active participants reported on line 7a of the Form 5500 2015-01-01 70
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 65
Total of all active and inactive participants 2015-01-01 135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2015-01-01 0
Total participants 2015-01-01 135
Number of participants with account balances 2015-01-01 126
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2015-01-01 19
2014: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year 2014-01-01 118
Total number of active participants reported on line 7a of the Form 5500 2014-01-01 70
Number of other retired or separated participants entitled to future benefits 2014-01-01 53
Total of all active and inactive participants 2014-01-01 123
Total participants 2014-01-01 123
Number of participants with account balances 2014-01-01 108
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2014-01-01 13

Measure	Date	Value
2017: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	141
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	188
Number of retired or separated participants receiving benefits	2017-01-01	0
Number of other retired or separated participants entitled to future benefits	2017-01-01	144
Total of all active and inactive participants	2017-01-01	332
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2017-01-01	0
Total participants	2017-01-01	332
Number of participants with account balances	2017-01-01	289
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2017-01-01	18
2016: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	135
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	66
Number of retired or separated participants receiving benefits	2016-01-01	0
Number of other retired or separated participants entitled to future benefits	2016-01-01	75
Total of all active and inactive participants	2016-01-01	141
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2016-01-01	0
Total participants	2016-01-01	141
Number of participants with account balances	2016-01-01	135
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2016-01-01	20
2015: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-01-01	123
Total number of active participants reported on line 7a of the Form 5500	2015-01-01	70
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	65
Total of all active and inactive participants	2015-01-01	135
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2015-01-01	0
Total participants	2015-01-01	135
Number of participants with account balances	2015-01-01	126
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2015-01-01	19
2014: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2014 401k membership
Total participants, beginning-of-year	2014-01-01	118
Total number of active participants reported on line 7a of the Form 5500	2014-01-01	70
Number of other retired or separated participants entitled to future benefits	2014-01-01	53
Total of all active and inactive participants	2014-01-01	123
Total participants	2014-01-01	123
Number of participants with account balances	2014-01-01	108
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2014-01-01	13

Financial Data on BI-RITE MARKET 18TH ST. RETIREMENT PLAN

Measure	Date	Value
2017 : BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2017 401k financial data
Total transfer of assets to this plan	2017-12-31	$3,330,568
Total income from all sources (including contributions)	2017-12-31	$1,144,798
Total of all expenses incurred	2017-12-31	$188,149
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2017-12-31	$186,074
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2017-12-31	$588,784
Value of total assets at end of year	2017-12-31	$7,404,082
Value of total assets at beginning of year	2017-12-31	$3,116,865
Total of administrative expenses incurred including professional, contract, advisory and management fees	2017-12-31	$2,075
Total interest from all sources	2017-12-31	$1,107
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2017-12-31	No
Administrative expenses professional fees incurred	2017-12-31	$2,075
Was this plan covered by a fidelity bond	2017-12-31	Yes
Value of fidelity bond cover	2017-12-31	$400,000
If this is an individual account plan, was there a blackout period	2017-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2017-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2017-12-31	No
Contributions received from participants	2017-12-31	$249,194
Participant contributions at end of year	2017-12-31	$102,077
Income. Received or receivable in cash from other sources (including rollovers)	2017-12-31	$129,821
Total non interest bearing cash at end of year	2017-12-31	$7,554
Total non interest bearing cash at beginning of year	2017-12-31	$7,970
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2017-12-31	No
Income. Non cash contributions	2017-12-31	$0
Value of net income/loss	2017-12-31	$956,649
Value of net assets at end of year (total assets less liabilities)	2017-12-31	$7,404,082
Value of net assets at beginning of year (total assets less liabilities)	2017-12-31	$3,116,865
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2017-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2017-12-31	No
Were any leases to which the plan was party in default or uncollectible	2017-12-31	No
Value of interest in pooled separate accounts at end of year	2017-12-31	$7,294,451
Value of interest in pooled separate accounts at beginning of year	2017-12-31	$3,108,895
Interest on participant loans	2017-12-31	$1,107
Net investment gain/loss from pooled separate accounts	2017-12-31	$554,907
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2017-12-31	No
Was there a failure to transmit to the plan any participant contributions	2017-12-31	No
Has the plan failed to provide any benefit when due under the plan	2017-12-31	No
Contributions received in cash from employer	2017-12-31	$209,769
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2017-12-31	$186,074
Did the plan have assets held for investment	2017-12-31	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	2017-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2017-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2017-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2017-12-31	Disclaimer
Accountancy firm name	2017-12-31	JOHANSON & YAU ACCOUNTANCY CORP.
Accountancy firm EIN	2017-12-31	942702860
2016 : BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2016 401k financial data
Total income from all sources (including contributions)	2016-12-31	$770,947
Total of all expenses incurred	2016-12-31	$185,349
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2016-12-31	$184,449
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2016-12-31	$544,287
Value of total assets at end of year	2016-12-31	$3,116,865
Value of total assets at beginning of year	2016-12-31	$2,531,267
Total of administrative expenses incurred including professional, contract, advisory and management fees	2016-12-31	$900
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2016-12-31	No
Administrative expenses professional fees incurred	2016-12-31	$900
Was this plan covered by a fidelity bond	2016-12-31	Yes
Value of fidelity bond cover	2016-12-31	$300,000
If this is an individual account plan, was there a blackout period	2016-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2016-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2016-12-31	No
Contributions received from participants	2016-12-31	$223,743
Income. Received or receivable in cash from other sources (including rollovers)	2016-12-31	$96,839
Total non interest bearing cash at end of year	2016-12-31	$7,970
Total non interest bearing cash at beginning of year	2016-12-31	$385
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2016-12-31	No
Value of net income/loss	2016-12-31	$585,598
Value of net assets at end of year (total assets less liabilities)	2016-12-31	$3,116,865
Value of net assets at beginning of year (total assets less liabilities)	2016-12-31	$2,531,267
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2016-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2016-12-31	No
Were any leases to which the plan was party in default or uncollectible	2016-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2016-12-31	$3,108,895
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2016-12-31	$2,530,882
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2016-12-31	$226,660
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2016-12-31	No
Was there a failure to transmit to the plan any participant contributions	2016-12-31	No
Has the plan failed to provide any benefit when due under the plan	2016-12-31	No
Contributions received in cash from employer	2016-12-31	$223,705
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2016-12-31	$184,449
Did the plan have assets held for investment	2016-12-31	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	2016-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2016-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2016-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2016-12-31	Disclaimer
Accountancy firm name	2016-12-31	DAVID J CORMIA, CPA
Accountancy firm EIN	2016-12-31	208298840
2015 : BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2015 401k financial data
Total transfer of assets from this plan	2015-12-31	$36,460
Total income from all sources (including contributions)	2015-12-31	$510,936
Total of all expenses incurred	2015-12-31	$105,749
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2015-12-31	$105,749
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2015-12-31	$566,707
Value of total assets at end of year	2015-12-31	$2,531,267
Value of total assets at beginning of year	2015-12-31	$2,162,540
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	$300,000
If this is an individual account plan, was there a blackout period	2015-12-31	No
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	$238,665
Income. Received or receivable in cash from other sources (including rollovers)	2015-12-31	$129,320
Total non interest bearing cash at end of year	2015-12-31	$385
Total non interest bearing cash at beginning of year	2015-12-31	$5,284
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
Income. Non cash contributions	2015-12-31	$0
Value of net income/loss	2015-12-31	$405,187
Value of net assets at end of year (total assets less liabilities)	2015-12-31	$2,531,267
Value of net assets at beginning of year (total assets less liabilities)	2015-12-31	$2,162,540
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 registered invesment companies (eg mutual funds) at end of year	2015-12-31	$2,530,882
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2015-12-31	$2,157,256
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2015-12-31	$-55,771
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	$198,722
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2015-12-31	$105,749
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	DAVID J. CORMIA, CPA
Accountancy firm EIN	2015-12-31	208298840
2014 : BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2014 401k financial data
Total income from all sources (including contributions)	2014-12-31	$298,814
Total of all expenses incurred	2014-12-31	$583,129
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2014-12-31	$583,129
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2014-12-31	$165,727
Value of total assets at end of year	2014-12-31	$2,162,540
Value of total assets at beginning of year	2014-12-31	$2,446,855
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	$150,000
If this is an individual account plan, was there a blackout period	2014-12-31	No
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	$159,909
Income. Received or receivable in cash from other sources (including rollovers)	2014-12-31	$5,818
Total non interest bearing cash at end of year	2014-12-31	$5,284
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
Value of net income/loss	2014-12-31	$-284,315
Value of net assets at end of year (total assets less liabilities)	2014-12-31	$2,162,540
Value of net assets at beginning of year (total assets less liabilities)	2014-12-31	$2,446,855
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 registered invesment companies (eg mutual funds) at end of year	2014-12-31	$2,157,256
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2014-12-31	$2,446,855
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2014-12-31	$133,087
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
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2014-12-31	$583,129
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	DAVID J. CORMIA, CPA
Accountancy firm EIN	2014-12-31	208298840

Form 5500 Responses for BI-RITE MARKET 18TH ST. RETIREMENT PLAN

2017: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan funding arrangement – Trust	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement - Trust	Yes
2016: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan funding arrangement – Trust	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement - Trust	Yes
2015: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2015 form 5500 responses
2015-01-01	Type of plan entity	Single employer plan
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: BI-RITE MARKET 18TH ST. RETIREMENT PLAN 2014 form 5500 responses
2014-01-01	Type of plan entity	Single employer plan
2014-01-01	Plan funding arrangement – Trust	Yes
2014-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

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

Policy contract number

102342

Policy instance

Insurance contract or identification number	102342
Number of Individuals Covered	296
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $10,666
Total amount of fees paid to insurance company	USD $2,167
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	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 $8,854
Amount paid for insurance broker fees	92
Additional information about fees paid to insurance broker	BROKER COMMISSIONS AND FEES
Insurance broker organization code?	3
Insurance broker name	PLAN DESIGN CONSULTANTS, INC.

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

Policy contract number

102342

Policy instance

Insurance contract or identification number	102342
Number of Individuals Covered	130
Insurance policy start date	2015-01-01
Insurance policy end date	2015-12-31
Total amount of commissions paid to insurance broker	USD $5,728
Total amount of fees paid to insurance company	USD $1,128
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $5,620
Additional information about fees paid to insurance broker	BROKER COMMISSION
Insurance broker organization code?	6
Amount paid for insurance broker fees	1128
Insurance broker name	MORGAN STANLEY SMITH BARNEY

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

Policy contract number

65838

Policy instance

Insurance contract or identification number	65838
Number of Individuals Covered	118
Insurance policy start date	2014-01-01
Insurance policy end date	2014-12-31
Total amount of commissions paid to insurance broker	USD $5,950
Total amount of fees paid to insurance company	USD $108
Commission paid to Insurance Broker	USD $5,950
Insurance broker organization code?	4
Amount paid for insurance broker fees	108
Insurance broker name	MORGAN STANLEY SMITH BARNEY

Potentially related plans

BI-RITE MARKET, INC. HEALTH AND WELFARE PLAN [EIN = 823361014]

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Company Name:	BI-RITE MARKET INC.
Employer identification number (EIN):	203183322
NAIC Classification:	445110
NAIC Description:	Supermarkets and Other Grocery (except Convenience) Stores

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:	2005-03-09
Company Identification Number:	C2725944
Legal Registered Office Address:	3639 18th St San Francisco United States of America (USA) 94110