401k Plan data: MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN plan

MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN
Plan identification number	501

MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or 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

MAC ONE MIDWAY, LLC has sponsored the creation of one or more 401k plans.

Company Name: MAC ONE MIDWAY, LLC

Employer identification number (EIN): 363630500

NAIC Classification: 722511
NAIC Description: Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2017-01-01 GARY ELMORE GARY ELMORE 2018-10-04
501 2016-01-01 GARY ELMORE GARY ELMORE 2017-10-12

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2017-01-01	GARY ELMORE		GARY ELMORE	2018-10-04
501	2016-01-01	GARY ELMORE		GARY ELMORE	2017-10-12

Plan Statistics for MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN

401k plan membership statisitcs for MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN

Measure Date Value
2017: MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year 2017-01-01 115
Total number of active participants reported on line 7a of the Form 5500 2017-01-01 17
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 0
Total of all active and inactive participants 2017-01-01 17
2016: MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year 2016-01-01 202
Total number of active participants reported on line 7a of the Form 5500 2016-01-01 162
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 0
Total of all active and inactive participants 2016-01-01 162

Measure	Date	Value
2017: MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN 2017 401k membership
Total participants, beginning-of-year	2017-01-01	115
Total number of active participants reported on line 7a of the Form 5500	2017-01-01	17
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	0
Total of all active and inactive participants	2017-01-01	17
2016: MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN 2016 401k membership
Total participants, beginning-of-year	2016-01-01	202
Total number of active participants reported on line 7a of the Form 5500	2016-01-01	162
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	0
Total of all active and inactive participants	2016-01-01	162

Form 5500 Responses for MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN

2017: MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN 2017 form 5500 responses
2017-01-01	Type of plan entity	Single employer plan
2017-01-01	Submission has been amended	No
2017-01-01	This submission is the final filing	No
2017-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2017-01-01	Plan is a collectively bargained plan	No
2017-01-01	Plan funding arrangement – Insurance	Yes
2017-01-01	Plan benefit arrangement – Insurance	Yes
2016: MAC ONE MIDWAY, LLC HEALTH AND WELFARE PLAN 2016 form 5500 responses
2016-01-01	Type of plan entity	Single employer plan
2016-01-01	First time form 5500 has been submitted	Yes
2016-01-01	Submission has been amended	No
2016-01-01	This submission is the final filing	No
2016-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-01-01	Plan is a collectively bargained plan	No
2016-01-01	Plan funding arrangement – Insurance	Yes
2016-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )

Policy contract number

753644

Policy instance

Insurance contract or identification number	753644
Number of Individuals Covered	51
Insurance policy start date	2017-01-01
Insurance policy end date	2017-12-31
Total amount of commissions paid to insurance broker	USD $2,602
Total amount of fees paid to insurance company	USD $33,475
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 $553,681
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,602
Amount paid for insurance broker fees	33475
Additional information about fees paid to insurance broker	SERVICE FEE AGREEMENT AND BONUS
Insurance broker organization code?	3
Insurance broker name	ASSURANCE AGENCY

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Company Name:	MAC ONE MIDWAY, LLC
Employer identification number (EIN):	363630500
NAIC Classification:	722511
NAIC Description:	Full-Service Restaurants