401k Plan data: RUBY'S DINER, INC. GROUP HEALTH AND WELFARE PLAN plan

RUBY'S DINER, INC. GROUP HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	RUBY'S DINER, INC. GROUP HEALTH AND WELFARE PLAN
Plan identification number	501

RUBY'S DINER, INC. GROUP HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Death benefits (include travel accident but not life insurance) 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

RUBY'S DINER, INC. has sponsored the creation of one or more 401k plans.

Company Name: RUBY'S DINER, INC.

Employer identification number (EIN): 330098143

NAIC Classification: 722511
NAIC Description: Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan RUBY'S DINER, INC. GROUP HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2015-04-01 DERENICE HERNANDEZ
501 2015-04-01 DERENICE HERNANDEZ

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2015-04-01	DERENICE HERNANDEZ
501	2015-04-01	DERENICE HERNANDEZ

Plan Statistics for RUBY'S DINER, INC. GROUP HEALTH AND WELFARE PLAN

401k plan membership statisitcs for RUBY'S DINER, INC. GROUP HEALTH AND WELFARE PLAN

Measure Date Value
2015: RUBY'S DINER, INC. GROUP HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year 2015-04-01 121
Total number of active participants reported on line 7a of the Form 5500 2015-04-01 138
Number of retired or separated participants receiving benefits 2015-04-01 0
Number of other retired or separated participants entitled to future benefits 2015-04-01 0
Total of all active and inactive participants 2015-04-01 138

Measure	Date	Value
2015: RUBY'S DINER, INC. GROUP HEALTH AND WELFARE PLAN 2015 401k membership
Total participants, beginning-of-year	2015-04-01	121
Total number of active participants reported on line 7a of the Form 5500	2015-04-01	138
Number of retired or separated participants receiving benefits	2015-04-01	0
Number of other retired or separated participants entitled to future benefits	2015-04-01	0
Total of all active and inactive participants	2015-04-01	138

Form 5500 Responses for RUBY'S DINER, INC. GROUP HEALTH AND WELFARE PLAN

2015: RUBY'S DINER, INC. GROUP HEALTH AND WELFARE PLAN 2015 form 5500 responses
2015-04-01	Type of plan entity	Single employer plan
2015-04-01	First time form 5500 has been submitted	Yes
2015-04-01	Submission has been amended	No
2015-04-01	This submission is the final filing	No
2015-04-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-04-01	Plan is a collectively bargained plan	No
2015-04-01	Plan funding arrangement – Insurance	Yes
2015-04-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

14514

Policy instance

Insurance contract or identification number	14514
Number of Individuals Covered	129
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $3,138
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	Yes
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 $47,237
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

KM05997361

Policy instance

Insurance contract or identification number	KM05997361
Number of Individuals Covered	57
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $3,807
Total amount of fees paid to insurance company	USD $24
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
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 $28,028
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTH NET (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

S4326 ET AL

Policy instance

Insurance contract or identification number	S4326 ET AL
Number of Individuals Covered	63
Insurance policy start date	2015-04-01
Insurance policy end date	2016-03-31
Total amount of commissions paid to insurance broker	USD $20,354
Total amount of fees paid to insurance company	USD $4,240
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	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 $382,128
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	RUBY'S DINER, INC.
Employer identification number (EIN):	330098143
NAIC Classification:	722511
NAIC Description:	Full-Service Restaurants