401k Plan data: PAUL USA EMPLOYEE BENEFIT PLAN plan

PAUL USA EMPLOYEE BENEFIT PLAN 401k Plan overview

Plan Name	PAUL USA EMPLOYEE BENEFIT PLAN
Plan identification number	501

PAUL USA EMPLOYEE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Temporary disability (accident and sickness) Long-term disability cover Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

PAUL USA has sponsored the creation of one or more 401k plans.

Company Name: PAUL USA

Employer identification number (EIN): 270524574

NAIC Classification: 722513
NAIC Description: Limited-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PAUL USA EMPLOYEE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-04-01

Plan Statistics for PAUL USA EMPLOYEE BENEFIT PLAN

401k plan membership statisitcs for PAUL USA EMPLOYEE BENEFIT PLAN

Measure Date Value
2017: PAUL USA EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-04-01 117
Total number of active participants reported on line 7a of the Form 5500 2017-04-01 146
Number of retired or separated participants receiving benefits 2017-04-01 0
Number of other retired or separated participants entitled to future benefits 2017-04-01 0
Total of all active and inactive participants 2017-04-01 146

Measure	Date	Value
2017: PAUL USA EMPLOYEE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-04-01	117
Total number of active participants reported on line 7a of the Form 5500	2017-04-01	146
Number of retired or separated participants receiving benefits	2017-04-01	0
Number of other retired or separated participants entitled to future benefits	2017-04-01	0
Total of all active and inactive participants	2017-04-01	146

Form 5500 Responses for PAUL USA EMPLOYEE BENEFIT PLAN

2017: PAUL USA EMPLOYEE BENEFIT PLAN 2017 form 5500 responses
2017-04-01	Type of plan entity	Single employer plan
2017-04-01	First time form 5500 has been submitted	Yes
2017-04-01	Plan funding arrangement – Insurance	Yes
2017-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

1042926

Policy instance

Insurance contract or identification number	1042926
Number of Individuals Covered	23
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $1,373
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,990
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $944
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	CENTERSTONE INS. AND FIN. SERVICES

BLUE CROSS BLUE SHIELD OF MASSACHUSETTS, INC. (National Association of Insurance Commissioners NAIC id number: 53228 )

Policy contract number

8067674

Policy instance

Insurance contract or identification number	8067674
Number of Individuals Covered	7
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $1,800
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $40,944
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $1,800
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	UNKNOWN

CAREFIRST BLUECHOICE (National Association of Insurance Commissioners NAIC id number: 96202 )

Policy contract number

1TN1

Policy instance

Insurance contract or identification number	1TN1
Number of Individuals Covered	28
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $10,248
Total amount of fees paid to insurance company	USD $1,763
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $204,962
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,248
Amount paid for insurance broker fees	5
Additional information about fees paid to insurance broker	NON-MONETARY INCENTIVE
Insurance broker organization code?	3
Insurance broker name	BENEFITMALL/MATHER AND STROHL

MONY (National Association of Insurance Commissioners NAIC id number: 78077 )

Policy contract number

000998

Policy instance

Insurance contract or identification number	000998
Number of Individuals Covered	146
Insurance policy start date	2017-07-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 39616 )

Policy contract number

30066746

Policy instance

Insurance contract or identification number	30066746
Number of Individuals Covered	16
Insurance policy start date	2017-04-01
Insurance policy end date	2018-03-31
Total amount of commissions paid to insurance broker	USD $109
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,092
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $109
Amount paid for insurance broker fees	0
Insurance broker organization code?	3
Insurance broker name	TINA WRIGHT

Potentially related plans

PAUL USA 401K PLAN [EIN = 275254574]

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Company Name:	PAUL USA
Employer identification number (EIN):	270524574
NAIC Classification:	722513
NAIC Description:	Limited-Service Restaurants