401k Plan data: PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN plan

PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN 401k Plan overview

Plan Name	PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN
Plan identification number	501

PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

WONT STOP HOSPITALITY INC has sponsored the creation of one or more 401k plans.

Company Name: WONT STOP HOSPITALITY INC

Employer identification number (EIN): 271405682

NAIC Classification: 722513
NAIC Description: Limited-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2020-01-01
501 2019-01-01

Plan Statistics for PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN

401k plan membership statisitcs for PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN

Measure Date Value
2020: PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 105
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 84
Total of all active and inactive participants 2020-01-01 84
Total participants 2020-01-01 84
2019: PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 104
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 105
Total of all active and inactive participants 2019-01-01 105
Total participants 2019-01-01 105

Measure	Date	Value
2020: PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	105
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	84
Total of all active and inactive participants	2020-01-01	84
Total participants	2020-01-01	84
2019: PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	104
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	105
Total of all active and inactive participants	2019-01-01	105
Total participants	2019-01-01	105

Form 5500 Responses for PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN

2020: PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	No
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: PATACHOU ADMINISTRATIVE SERVICES MEDICAL PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	First time form 5500 has been submitted	Yes
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

W11612

Policy instance

Insurance contract or identification number	W11612
Number of Individuals Covered	84
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $27,261
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $392,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $27,261
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

ANTHEM INSURANCE COMPANIES, INC (National Association of Insurance Commissioners NAIC id number: 28207 )

Policy contract number

W11612

Policy instance

Insurance contract or identification number	W11612
Number of Individuals Covered	105
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $29,536
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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	Yes
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
Welfare Benefit Premiums Paid to Carrier	USD $494,442
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $29,536
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	WONT STOP HOSPITALITY INC
Employer identification number (EIN):	271405682
NAIC Classification:	722513
NAIC Description:	Limited-Service Restaurants