401k Plan data: 739 IBERVILLE LLC DBA RELIX'S RESTAURANT AND BAR HEALTH AND WELFARE plan

739 IBERVILLE LLC DBA RELIX'S RESTAURANT AND BAR HEALTH AND WELFARE 401k Plan overview

Plan Name	739 IBERVILLE LLC DBA RELIX'S RESTAURANT AND BAR HEALTH AND WELFARE
Plan identification number	501

739 IBERVILLE LLC DBA RELIX'S RESTAURANT AND BAR HEALTH AND WELFARE 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) Other welfare benefit cover

401k Sponsoring company profile

739 IBERVILLE, LLC has sponsored the creation of one or more 401k plans.

Company Name: 739 IBERVILLE, LLC

Employer identification number (EIN): 461349509

NAIC Classification: 722511
NAIC Description: Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan 739 IBERVILLE LLC DBA RELIX'S RESTAURANT AND BAR HEALTH AND WELFARE

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 GINA BIVALACQUA 2024-06-11

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2023-01-01	GINA BIVALACQUA	2024-06-11

Plan Statistics for 739 IBERVILLE LLC DBA RELIX'S RESTAURANT AND BAR HEALTH AND WELFARE

401k plan membership statisitcs for 739 IBERVILLE LLC DBA RELIX'S RESTAURANT AND BAR HEALTH AND WELFARE

Measure Date Value
2023: 739 IBERVILLE LLC DBA RELIX'S RESTAURANT AND BAR HEALTH AND WELFARE 2023 401k membership
Total participants, beginning-of-year 2023-01-01 246
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 175
Number of retired or separated participants receiving benefits 2023-01-01 1
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 176
Number of employers contributing to the scheme 2023-01-01 0

Measure	Date	Value
2023: 739 IBERVILLE LLC DBA RELIX'S RESTAURANT AND BAR HEALTH AND WELFARE 2023 401k membership
Total participants, beginning-of-year	2023-01-01	246
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	175
Number of retired or separated participants receiving benefits	2023-01-01	1
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	176
Number of employers contributing to the scheme	2023-01-01	0

Form 5500 Responses for 739 IBERVILLE LLC DBA RELIX'S RESTAURANT AND BAR HEALTH AND WELFARE

2023: 739 IBERVILLE LLC DBA RELIX'S RESTAURANT AND BAR HEALTH AND WELFARE 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	First time form 5500 has been submitted	Yes
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF LOUISIANA (National Association of Insurance Commissioners NAIC id number: 81200 )

Policy contract number

28S35ERC

Policy instance

Insurance contract or identification number	28S35ERC
Number of Individuals Covered	26
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $6,811
Total amount of fees paid to insurance company	USD $6,362
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $399,900
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

COLONIAL LIFE & ACCIDENT INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 62049 )

Policy contract number

E5821095

Policy instance

Insurance contract or identification number	E5821095
Number of Individuals Covered	26
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,585
Total amount of fees paid to insurance company	USD $1,907
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $14,615
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

EAP

Policy instance

Insurance contract or identification number	EAP
Number of Individuals Covered	400
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	EMPLOYEE ASSISTANCE PROGRAM
Welfare Benefit Premiums Paid to Carrier	USD $4,788
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )

Policy contract number

960289

Policy instance

Insurance contract or identification number	960289
Number of Individuals Covered	171
Insurance policy start date	2023-05-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $6,207
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL
Welfare Benefit Premiums Paid to Carrier	USD $35,002
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

171394

Policy instance

Insurance contract or identification number	171394
Number of Individuals Covered	244
Insurance policy start date	2023-05-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $3,793
Total amount of fees paid to insurance company	USD $0
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	Yes
Long Term Disability Insurance Welfare Benefit	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT,EMPLOYEE ASSISTANCE PROGRAM
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	739 IBERVILLE, LLC
Employer identification number (EIN):	461349509
NAIC Classification:	722511
NAIC Description:	Full-Service Restaurants