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MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 401k Plan overview

Plan NameMISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN
Plan identification number 501

MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Long-term disability cover
  • 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

MISSOURI JACK LLC has sponsored the creation of one or more 401k plans.

Company Name:MISSOURI JACK LLC
Employer identification number (EIN):452037521
NAIC Classification:722513
NAIC Description:Limited-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012022-01-01HAMID SHARAFATIAN2023-09-13
5012021-01-01HAMID SHARAFATIAN2022-09-28
5012020-01-01HAMID SHARAFATIAN2021-10-14
5012019-01-01HAMID SHARAFATIAN2020-10-13

Plan Statistics for MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN

401k plan membership statisitcs for MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN

Measure Date Value
2022: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year2022-01-01190
Total number of active participants reported on line 7a of the Form 55002022-01-0172
Number of retired or separated participants receiving benefits2022-01-010
Number of other retired or separated participants entitled to future benefits2022-01-010
Total of all active and inactive participants2022-01-0172
Number of employers contributing to the scheme2022-01-010
2021: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year2021-01-01218
Total number of active participants reported on line 7a of the Form 55002021-01-01190
Number of retired or separated participants receiving benefits2021-01-010
Number of other retired or separated participants entitled to future benefits2021-01-010
Total of all active and inactive participants2021-01-01190
Number of employers contributing to the scheme2021-01-010
2020: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year2020-01-01217
Total number of active participants reported on line 7a of the Form 55002020-01-01218
Number of retired or separated participants receiving benefits2020-01-010
Number of other retired or separated participants entitled to future benefits2020-01-010
Total of all active and inactive participants2020-01-01218
Number of employers contributing to the scheme2020-01-010
2019: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year2019-01-01100
Total number of active participants reported on line 7a of the Form 55002019-01-01217
Number of retired or separated participants receiving benefits2019-01-010
Number of other retired or separated participants entitled to future benefits2019-01-010
Total of all active and inactive participants2019-01-01217
Number of employers contributing to the scheme2019-01-010

Form 5500 Responses for MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN

2022: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2022 form 5500 responses
2022-01-01Type of plan entitySingle employer plan
2022-01-01Plan funding arrangement – InsuranceYes
2022-01-01Plan benefit arrangement – InsuranceYes
2021: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2021 form 5500 responses
2021-01-01Type of plan entitySingle employer plan
2021-01-01Plan funding arrangement – InsuranceYes
2021-01-01Plan benefit arrangement – InsuranceYes
2020: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2020 form 5500 responses
2020-01-01Type of plan entitySingle employer plan
2020-01-01Plan funding arrangement – InsuranceYes
2020-01-01Plan benefit arrangement – InsuranceYes
2019: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2019 form 5500 responses
2019-01-01Type of plan entitySingle employer plan
2019-01-01First time form 5500 has been submittedYes
2019-01-01Plan funding arrangement – InsuranceYes
2019-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberW61493
Policy instance 3
Insurance contract or identification numberW61493
Number of Individuals Covered0
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $30,401
Total amount of fees paid to insurance companyUSD $1,138
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,401
Amount paid for insurance broker fees1138
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10248731
Policy instance 2
Insurance contract or identification number10248731
Number of Individuals Covered0
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $1,281
Total amount of fees paid to insurance companyUSD $0
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $8,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,281
Amount paid for insurance broker fees0
Insurance broker organization code?3
HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )
Policy contract numberW61493
Policy instance 1
Insurance contract or identification numberW61493
Number of Individuals Covered136
Insurance policy start date2022-01-01
Insurance policy end date2022-12-31
Total amount of commissions paid to insurance brokerUSD $30,401
Total amount of fees paid to insurance companyUSD $1,138
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $765,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,401
Amount paid for insurance broker fees1138
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10248731
Policy instance 3
Insurance contract or identification number10248731
Number of Individuals Covered190
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $3,060
Total amount of fees paid to insurance companyUSD $1,212
Health Insurance Welfare BenefitNo
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitYes
Unemployment Insurance Welfare BenefitNo
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $20,398
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,060
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBONUS
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberW61493
Policy instance 2
Insurance contract or identification numberW61493
Number of Individuals Covered0
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $29,602
Total amount of fees paid to insurance companyUSD $1,487
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $6,520
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $29,602
Amount paid for insurance broker fees1487
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )
Policy contract numberW61493
Policy instance 1
Insurance contract or identification numberW61493
Number of Individuals Covered132
Insurance policy start date2021-01-01
Insurance policy end date2021-12-31
Total amount of commissions paid to insurance brokerUSD $29,602
Total amount of fees paid to insurance companyUSD $1,487
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $676,284
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $29,602
Amount paid for insurance broker fees1487
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract numberW61493
Policy instance 3
Insurance contract or identification numberW61493
Number of Individuals Covered32
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $522
Total amount of fees paid to insurance companyUSD $11
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $6,689
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $522
Amount paid for insurance broker fees11
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10248731
Policy instance 2
Insurance contract or identification number10248731
Number of Individuals Covered218
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $605
Total amount of fees paid to insurance companyUSD $244
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $4,035
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $605
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerBROKER BONUS
HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )
Policy contract numberW61493
Policy instance 1
Insurance contract or identification numberW61493
Number of Individuals Covered151
Insurance policy start date2020-01-01
Insurance policy end date2020-12-31
Total amount of commissions paid to insurance brokerUSD $26,100
Total amount of fees paid to insurance companyUSD $546
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $603,384
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $26,100
Amount paid for insurance broker fees546
Additional information about fees paid to insurance brokerFEES
Insurance broker organization code?3
HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )
Policy contract number253043
Policy instance 3
Insurance contract or identification number253043
Number of Individuals Covered174
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $37,639
Total amount of fees paid to insurance companyUSD $2
Health Insurance Welfare BenefitYes
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Welfare Benefit Premiums Paid to CarrierUSD $928,610
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $34,997
Amount paid for insurance broker fees0
Insurance broker organization code?3
Additional information about fees paid to insurance brokerFEES
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number10248731
Policy instance 2
Insurance contract or identification number10248731
Number of Individuals Covered217
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $732
Total amount of fees paid to insurance companyUSD $237
Life Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to CarrierUSD $4,876
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $732
Amount paid for insurance broker fees237
Additional information about fees paid to insurance brokerBROKER BONUS
Insurance broker organization code?3
ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )
Policy contract number221325
Policy instance 1
Insurance contract or identification number221325
Number of Individuals Covered151
Insurance policy start date2019-01-01
Insurance policy end date2019-12-31
Total amount of commissions paid to insurance brokerUSD $2,406
Total amount of fees paid to insurance companyUSD $0
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $21,304
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $1,952
Amount paid for insurance broker fees0
Insurance broker organization code?3

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