401k Plan data: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN plan

ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN
Plan identification number	505

ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 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 Other welfare benefit cover

401k Sponsoring company profile

ORIGINAL BREAD, INC. has sponsored the creation of one or more 401k plans.

Company Name: ORIGINAL BREAD, INC.

Employer identification number (EIN): 481134142

NAIC Classification: 722210
NAIC Description: Limited-Service Eating Places

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
505 2016-03-01 CHRISTIE GLAESER
505 2015-03-01 CHRISTIE GLAESER
505 2014-03-01 CHRISTIE GLAESER
505 2013-03-01 CHRISTIE GLAESER
505 2012-03-01 CHRISTIE GLAESER
505 2012-02-01 CHRISTIE GLAESER
505 2011-02-01 CHRISTIE GLAESER
505 2009-02-01 CHRISTIE GLAESER
505 2008-02-01 CHRISTIE GLAESER
505 2007-02-01 CHRISTIE GLAESER
505 2006-02-01 CHRISTIE GLAESER
505 2005-02-01 CHRISTIE GLAESER
505 2004-02-01 CHRISTIE GLAESER
505 2003-02-01 CHRISTIE GLAESER

Plan id#	Filing Submission Date	Name of Administrator
505	2016-03-01	CHRISTIE GLAESER
505	2015-03-01	CHRISTIE GLAESER
505	2014-03-01	CHRISTIE GLAESER
505	2013-03-01	CHRISTIE GLAESER
505	2012-03-01	CHRISTIE GLAESER
505	2012-02-01	CHRISTIE GLAESER
505	2011-02-01	CHRISTIE GLAESER
505	2009-02-01	CHRISTIE GLAESER
505	2008-02-01	CHRISTIE GLAESER
505	2007-02-01	CHRISTIE GLAESER
505	2006-02-01	CHRISTIE GLAESER
505	2005-02-01	CHRISTIE GLAESER
505	2004-02-01	CHRISTIE GLAESER
505	2003-02-01	CHRISTIE GLAESER

Plan Statistics for ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN

Measure Date Value
2016: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-03-01 244
Total number of active participants reported on line 7a of the Form 5500 2016-03-01 242
Number of retired or separated participants receiving benefits 2016-03-01 0
Number of other retired or separated participants entitled to future benefits 2016-03-01 0
Total of all active and inactive participants 2016-03-01 242
2015: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-03-01 125
Total number of active participants reported on line 7a of the Form 5500 2015-03-01 125
Number of retired or separated participants receiving benefits 2015-03-01 2
Number of other retired or separated participants entitled to future benefits 2015-03-01 2
Total of all active and inactive participants 2015-03-01 129
2014: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year 2014-03-01 239
Total number of active participants reported on line 7a of the Form 5500 2014-03-01 250
Number of retired or separated participants receiving benefits 2014-03-01 0
Number of other retired or separated participants entitled to future benefits 2014-03-01 0
Total of all active and inactive participants 2014-03-01 250
2013: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year 2013-03-01 234
Total number of active participants reported on line 7a of the Form 5500 2013-03-01 234
Number of retired or separated participants receiving benefits 2013-03-01 1
Number of other retired or separated participants entitled to future benefits 2013-03-01 0
Total of all active and inactive participants 2013-03-01 235
2012: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year 2012-03-01 258
Total number of active participants reported on line 7a of the Form 5500 2012-03-01 206
Number of retired or separated participants receiving benefits 2012-03-01 0
Number of other retired or separated participants entitled to future benefits 2012-03-01 0
Total of all active and inactive participants 2012-03-01 206
Total participants, beginning-of-year 2012-02-01 223
Total number of active participants reported on line 7a of the Form 5500 2012-02-01 221
Number of retired or separated participants receiving benefits 2012-02-01 2
Number of other retired or separated participants entitled to future benefits 2012-02-01 0
Total of all active and inactive participants 2012-02-01 223
2011: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year 2011-02-01 213
Total number of active participants reported on line 7a of the Form 5500 2011-02-01 221
Number of retired or separated participants receiving benefits 2011-02-01 2
Number of other retired or separated participants entitled to future benefits 2011-02-01 0
Total of all active and inactive participants 2011-02-01 223
2009: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year 2009-02-01 198
Total number of active participants reported on line 7a of the Form 5500 2009-02-01 196
Number of retired or separated participants receiving benefits 2009-02-01 1
Number of other retired or separated participants entitled to future benefits 2009-02-01 0
Total of all active and inactive participants 2009-02-01 197
2008: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2008 401k membership
Total participants, beginning-of-year 2008-02-01 177
Total number of active participants reported on line 7a of the Form 5500 2008-02-01 197
Number of retired or separated participants receiving benefits 2008-02-01 1
Number of other retired or separated participants entitled to future benefits 2008-02-01 0
Total of all active and inactive participants 2008-02-01 198
2007: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2007 401k membership
Total participants, beginning-of-year 2007-02-01 156
Total number of active participants reported on line 7a of the Form 5500 2007-02-01 176
Number of retired or separated participants receiving benefits 2007-02-01 1
Number of other retired or separated participants entitled to future benefits 2007-02-01 0
Total of all active and inactive participants 2007-02-01 177
2006: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2006 401k membership
Total participants, beginning-of-year 2006-02-01 138
Total number of active participants reported on line 7a of the Form 5500 2006-02-01 155
Number of retired or separated participants receiving benefits 2006-02-01 1
Number of other retired or separated participants entitled to future benefits 2006-02-01 0
Total of all active and inactive participants 2006-02-01 156
2005: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2005 401k membership
Total participants, beginning-of-year 2005-02-01 120
Total number of active participants reported on line 7a of the Form 5500 2005-02-01 137
Number of retired or separated participants receiving benefits 2005-02-01 1
Number of other retired or separated participants entitled to future benefits 2005-02-01 0
Total of all active and inactive participants 2005-02-01 138
2004: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2004 401k membership
Total participants, beginning-of-year 2004-02-01 106
Total number of active participants reported on line 7a of the Form 5500 2004-02-01 119
Number of retired or separated participants receiving benefits 2004-02-01 1
Number of other retired or separated participants entitled to future benefits 2004-02-01 0
Total of all active and inactive participants 2004-02-01 120
2003: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2003 401k membership
Total participants, beginning-of-year 2003-02-01 104
Total number of active participants reported on line 7a of the Form 5500 2003-02-01 105
Number of retired or separated participants receiving benefits 2003-02-01 1
Number of other retired or separated participants entitled to future benefits 2003-02-01 0
Total of all active and inactive participants 2003-02-01 106

Measure	Date	Value
2016: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-03-01	244
Total number of active participants reported on line 7a of the Form 5500	2016-03-01	242
Number of retired or separated participants receiving benefits	2016-03-01	0
Number of other retired or separated participants entitled to future benefits	2016-03-01	0
Total of all active and inactive participants	2016-03-01	242
2015: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-03-01	125
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	125
Number of retired or separated participants receiving benefits	2015-03-01	2
Number of other retired or separated participants entitled to future benefits	2015-03-01	2
Total of all active and inactive participants	2015-03-01	129
2014: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2014 401k membership
Total participants, beginning-of-year	2014-03-01	239
Total number of active participants reported on line 7a of the Form 5500	2014-03-01	250
Number of retired or separated participants receiving benefits	2014-03-01	0
Number of other retired or separated participants entitled to future benefits	2014-03-01	0
Total of all active and inactive participants	2014-03-01	250
2013: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2013 401k membership
Total participants, beginning-of-year	2013-03-01	234
Total number of active participants reported on line 7a of the Form 5500	2013-03-01	234
Number of retired or separated participants receiving benefits	2013-03-01	1
Number of other retired or separated participants entitled to future benefits	2013-03-01	0
Total of all active and inactive participants	2013-03-01	235
2012: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2012 401k membership
Total participants, beginning-of-year	2012-03-01	258
Total number of active participants reported on line 7a of the Form 5500	2012-03-01	206
Number of retired or separated participants receiving benefits	2012-03-01	0
Number of other retired or separated participants entitled to future benefits	2012-03-01	0
Total of all active and inactive participants	2012-03-01	206
Total participants, beginning-of-year	2012-02-01	223
Total number of active participants reported on line 7a of the Form 5500	2012-02-01	221
Number of retired or separated participants receiving benefits	2012-02-01	2
Number of other retired or separated participants entitled to future benefits	2012-02-01	0
Total of all active and inactive participants	2012-02-01	223
2011: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2011 401k membership
Total participants, beginning-of-year	2011-02-01	213
Total number of active participants reported on line 7a of the Form 5500	2011-02-01	221
Number of retired or separated participants receiving benefits	2011-02-01	2
Number of other retired or separated participants entitled to future benefits	2011-02-01	0
Total of all active and inactive participants	2011-02-01	223
2009: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2009 401k membership
Total participants, beginning-of-year	2009-02-01	198
Total number of active participants reported on line 7a of the Form 5500	2009-02-01	196
Number of retired or separated participants receiving benefits	2009-02-01	1
Number of other retired or separated participants entitled to future benefits	2009-02-01	0
Total of all active and inactive participants	2009-02-01	197
2008: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2008 401k membership
Total participants, beginning-of-year	2008-02-01	177
Total number of active participants reported on line 7a of the Form 5500	2008-02-01	197
Number of retired or separated participants receiving benefits	2008-02-01	1
Number of other retired or separated participants entitled to future benefits	2008-02-01	0
Total of all active and inactive participants	2008-02-01	198
2007: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2007 401k membership
Total participants, beginning-of-year	2007-02-01	156
Total number of active participants reported on line 7a of the Form 5500	2007-02-01	176
Number of retired or separated participants receiving benefits	2007-02-01	1
Number of other retired or separated participants entitled to future benefits	2007-02-01	0
Total of all active and inactive participants	2007-02-01	177
2006: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2006 401k membership
Total participants, beginning-of-year	2006-02-01	138
Total number of active participants reported on line 7a of the Form 5500	2006-02-01	155
Number of retired or separated participants receiving benefits	2006-02-01	1
Number of other retired or separated participants entitled to future benefits	2006-02-01	0
Total of all active and inactive participants	2006-02-01	156
2005: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2005 401k membership
Total participants, beginning-of-year	2005-02-01	120
Total number of active participants reported on line 7a of the Form 5500	2005-02-01	137
Number of retired or separated participants receiving benefits	2005-02-01	1
Number of other retired or separated participants entitled to future benefits	2005-02-01	0
Total of all active and inactive participants	2005-02-01	138
2004: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2004 401k membership
Total participants, beginning-of-year	2004-02-01	106
Total number of active participants reported on line 7a of the Form 5500	2004-02-01	119
Number of retired or separated participants receiving benefits	2004-02-01	1
Number of other retired or separated participants entitled to future benefits	2004-02-01	0
Total of all active and inactive participants	2004-02-01	120
2003: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2003 401k membership
Total participants, beginning-of-year	2003-02-01	104
Total number of active participants reported on line 7a of the Form 5500	2003-02-01	105
Number of retired or separated participants receiving benefits	2003-02-01	1
Number of other retired or separated participants entitled to future benefits	2003-02-01	0
Total of all active and inactive participants	2003-02-01	106

Form 5500 Responses for ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN

2016: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	Submission has been amended	No
2016-03-01	This submission is the final filing	No
2016-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-03-01	Plan is a collectively bargained plan	No
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes
2015: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Submission has been amended	No
2015-03-01	This submission is the final filing	No
2015-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-03-01	Plan is a collectively bargained plan	No
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2014: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2014 form 5500 responses
2014-03-01	Type of plan entity	Single employer plan
2014-03-01	Submission has been amended	No
2014-03-01	This submission is the final filing	No
2014-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2014-03-01	Plan is a collectively bargained plan	No
2014-03-01	Plan funding arrangement – Insurance	Yes
2014-03-01	Plan benefit arrangement – Insurance	Yes
2013: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2013 form 5500 responses
2013-03-01	Type of plan entity	Single employer plan
2013-03-01	Submission has been amended	No
2013-03-01	This submission is the final filing	No
2013-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2013-03-01	Plan is a collectively bargained plan	No
2013-03-01	Plan funding arrangement – Insurance	Yes
2013-03-01	Plan benefit arrangement – Insurance	Yes
2012: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2012 form 5500 responses
2012-03-01	Type of plan entity	Single employer plan
2012-03-01	Submission has been amended	Yes
2012-03-01	This submission is the final filing	No
2012-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2012-03-01	Plan is a collectively bargained plan	No
2012-03-01	Plan funding arrangement – Insurance	Yes
2012-03-01	Plan benefit arrangement – Insurance	Yes
2012-02-01	Type of plan entity	Single employer plan
2012-02-01	Submission has been amended	No
2012-02-01	This submission is the final filing	No
2012-02-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2012-02-01	Plan is a collectively bargained plan	No
2012-02-01	Plan funding arrangement – Insurance	Yes
2012-02-01	Plan benefit arrangement – Insurance	Yes
2011: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2011 form 5500 responses
2011-02-01	Type of plan entity	Single employer plan
2011-02-01	Submission has been amended	No
2011-02-01	This submission is the final filing	No
2011-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-02-01	Plan is a collectively bargained plan	No
2011-02-01	Plan funding arrangement – Insurance	Yes
2011-02-01	Plan benefit arrangement – Insurance	Yes
2009: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2009 form 5500 responses
2009-02-01	Type of plan entity	Single employer plan
2009-02-01	Submission has been amended	No
2009-02-01	This submission is the final filing	No
2009-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2009-02-01	Plan is a collectively bargained plan	No
2009-02-01	Plan funding arrangement – Insurance	Yes
2009-02-01	Plan benefit arrangement – Insurance	Yes
2008: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2008 form 5500 responses
2008-02-01	Type of plan entity	Single employer plan
2008-02-01	Submission has been amended	No
2008-02-01	This submission is the final filing	No
2008-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2008-02-01	Plan is a collectively bargained plan	No
2008-02-01	Plan funding arrangement – Insurance	Yes
2008-02-01	Plan benefit arrangement – Insurance	Yes
2007: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2007 form 5500 responses
2007-02-01	Type of plan entity	Single employer plan
2007-02-01	Submission has been amended	No
2007-02-01	This submission is the final filing	No
2007-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2007-02-01	Plan is a collectively bargained plan	No
2007-02-01	Plan funding arrangement – Insurance	Yes
2007-02-01	Plan benefit arrangement – Insurance	Yes
2006: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2006 form 5500 responses
2006-02-01	Type of plan entity	Single employer plan
2006-02-01	Submission has been amended	No
2006-02-01	This submission is the final filing	No
2006-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2006-02-01	Plan is a collectively bargained plan	No
2006-02-01	Plan funding arrangement – Insurance	Yes
2006-02-01	Plan benefit arrangement – Insurance	Yes
2005: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2005 form 5500 responses
2005-02-01	Type of plan entity	Single employer plan
2005-02-01	Submission has been amended	No
2005-02-01	This submission is the final filing	No
2005-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2005-02-01	Plan is a collectively bargained plan	No
2005-02-01	Plan funding arrangement – Insurance	Yes
2005-02-01	Plan benefit arrangement – Insurance	Yes
2004: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2004 form 5500 responses
2004-02-01	Type of plan entity	Single employer plan
2004-02-01	Submission has been amended	No
2004-02-01	This submission is the final filing	No
2004-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2004-02-01	Plan is a collectively bargained plan	No
2004-02-01	Plan funding arrangement – Insurance	Yes
2004-02-01	Plan benefit arrangement – Insurance	Yes
2003: ORIGINAL BREAD, INC. EMPLOYEE BENEFITS PLAN 2003 form 5500 responses
2003-02-01	Type of plan entity	Single employer plan
2003-02-01	First time form 5500 has been submitted	Yes
2003-02-01	Submission has been amended	No
2003-02-01	This submission is the final filing	No
2003-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2003-02-01	Plan is a collectively bargained plan	No
2003-02-01	Plan funding arrangement – Insurance	Yes
2003-02-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

LINCOLN NATIONAL LIFE INSURANCE CO (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010187246
Policy instance	1
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10187247 00000
Policy instance	2
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400001000 18111
Policy instance	3
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000403002840
Policy instance	4
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	000010187245
Policy instance	5
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	303586
Policy instance	6
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	753859
Policy instance	7
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	403002840
Policy instance	5
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	400001000-18111
Policy instance	4
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	753859
Policy instance	1
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	303586
Policy instance	6
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10187247 00000
Policy instance	2
THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )
Policy contract number	10187245 00000
Policy instance	3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	0753859
Policy instance	2
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	303586
Policy instance	3
KANAWHA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65110 )
Policy contract number	683789
Policy instance	1
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	683789
Policy instance	1
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	683789
Policy instance	1
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	011592
Policy instance	2
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	683789
Policy instance	1
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	011592
Policy instance	3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	011592
Policy instance	4
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	683789
Policy instance	1
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	011592
Policy instance	3
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	011592
Policy instance	4
SUN LIFE ASSURANCE COMPANY OF CANADA (National Association of Insurance Commissioners NAIC id number: 80802 )
Policy contract number	011592
Policy instance	2
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	683789
Policy instance	1
HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )
Policy contract number	683789
Policy instance	2
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 141920
Policy instance	3
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	G 158490
Policy instance	4
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	G 158490
Policy instance	4
HUMANA (National Association of Insurance Commissioners NAIC id number: 70580 )
Policy contract number	683789
Policy instance	2
HUMANA INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 73288 )
Policy contract number	683789
Policy instance	1
RELIANCE STANDARD LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68381 )
Policy contract number	GL 141920
Policy instance	3
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	230464
Policy instance	1
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	390936
Policy instance	1
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	474032
Policy instance	2
COVENTRY HEALTH CARE OF KANSAS, INC. (National Association of Insurance Commissioners NAIC id number: 95489 )
Policy contract number	5038140001
Policy instance	2
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number	390936
Policy instance	1
UNITEDHEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 79413 )
Policy contract number	0280501
Policy instance	1

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Company Name:	ORIGINAL BREAD, INC.
Employer identification number (EIN):	481134142
NAIC Classification:	722210
NAIC Description:	Limited-Service Eating Places