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BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN 401k Plan overview

Plan NameBLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN
Plan identification number 501

BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)

401k Sponsoring company profile

BLUE GOOSE CANTINA has sponsored the creation of one or more 401k plans.

Company Name:BLUE GOOSE CANTINA
Employer identification number (EIN):751975501
NAIC Classification:722511
NAIC Description:Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012017-01-01
5012017-01-01
5012017-01-01
5012017-01-01
5012016-01-01
5012015-01-01JEREMY MESEBERG

Plan Statistics for BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN

401k plan membership statisitcs for BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN

Measure Date Value
2017: BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN 2017 401k membership
Total participants, beginning-of-year2017-01-01209
Total number of active participants reported on line 7a of the Form 55002017-01-01209
Total of all active and inactive participants2017-01-01209
Total participants2017-01-01209
Number of participants with account balances2017-01-01227
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested2017-01-010
Number of employers contributing to the scheme2017-01-010
2016: BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN 2016 401k membership
Total participants, beginning-of-year2016-01-01192
Total number of active participants reported on line 7a of the Form 55002016-01-01242
Total of all active and inactive participants2016-01-01242
Total participants2016-01-01242
2015: BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN 2015 401k membership
Total participants, beginning-of-year2015-01-01192
Total number of active participants reported on line 7a of the Form 55002015-01-01129
Total of all active and inactive participants2015-01-01129
Total participants2015-01-01129

Financial Data on BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN

Measure Date Value
2015 : BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN 2015 401k financial data
Total unrealized appreciation/depreciation of assets2015-12-31$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2015-12-31$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)2015-12-31$0
Total income from all sources (including contributions)2015-12-31$229,526
Total loss/gain on sale of assets2015-12-31$0
Total of all expenses incurred2015-12-31$167,754
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others2015-12-31$35,274
Total contributions o plan (from employers,participants, others, non cash contrinutions)2015-12-31$229,526
Value of total assets at end of year2015-12-31$65,024
Value of total assets at beginning of year2015-12-31$3,252
Total of administrative expenses incurred including professional, contract, advisory and management fees2015-12-31$132,480
Total interest from all sources2015-12-31$0
Total dividends received (eg from common stock, registered investment company shares)2015-12-31$0
Administrative expenses professional fees incurred2015-12-31$65,985
Was this plan covered by a fidelity bond2015-12-31No
Administrative expenses (other) incurred2015-12-31$66,495
Value of net income/loss2015-12-31$61,772
Value of net assets at end of year (total assets less liabilities)2015-12-31$65,024
Value of net assets at beginning of year (total assets less liabilities)2015-12-31$3,252
Were any loans by the plan or fixed income obligations due to the plan in default2015-12-31No
Value of funds held in insurance company general accounts (unallocated contracts) at end of year2015-12-31$65,024
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year2015-12-31$3,252
Expenses. Payments to insurance carriers foe the provision of benefits2015-12-31$35,274
Contributions received in cash from employer2015-12-31$229,526

Form 5500 Responses for BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN

2017: BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN 2017 form 5500 responses
2017-01-01Type of plan entitySingle employer plan
2017-01-01Plan funding arrangement – InsuranceYes
2017-01-01Plan benefit arrangement – InsuranceYes
2016: BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN 2016 form 5500 responses
2016-01-01Type of plan entitySingle employer plan
2016-01-01Plan funding arrangement – General assets of the sponsorYes
2016-01-01Plan benefit arrangement – General assets of the sponsorYes
2015: BLUE GOOSE CANTINA EMPLOYEE GROUP HEALTH PLAN 2015 form 5500 responses
2015-01-01Type of plan entitySingle employer plan
2015-01-01First time form 5500 has been submittedYes
2015-01-01Submission has been amendedNo
2015-01-01This submission is the final filingNo
2015-01-01This return/report is a short plan year return/report (less than 12 months)No
2015-01-01Plan is a collectively bargained planNo
2015-01-01Plan funding arrangement – InsuranceYes
2015-01-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

ALLIED NATIONAL COMPANIES (National Association of Insurance Commissioners NAIC id number: 00000 )
Policy contract number280915
Policy instance 1
Insurance contract or identification number280915
Number of Individuals Covered129
Insurance policy start date2015-01-01
Insurance policy end date2015-12-31
Total amount of fees paid to insurance companyUSD $41,538
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 planNo
Contracts With Unallocated Funds Deposit Administration0
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 BenefitYes
Dental Insurance Welfare BenefitNo
Vision Insurance Welfare BenefitNo
Life Insurance Welfare BenefitNo
Temporary Disability Insurance Welfare BenefitNo
Long Term Disability Insurance Welfare BenefitNo
Unemployment Insurance Welfare BenefitNo
Were dividends or retroactive rate refunds paid in cash?No
Were dividends or retroactive rate refunds paid as a credit?No
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Amount paid for insurance broker fees16311
Insurance broker organization code?3
Insurance broker nameWAYNE A PETERSON

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