401k Plan data: CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT PLAN plan

CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT PLAN
Plan identification number	507

CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT 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) Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

CEO FOODS, INC. DBA EEGEES has sponsored the creation of one or more 401k plans.

Company Name: CEO FOODS, INC. DBA EEGEES

Employer identification number (EIN): 953981762

NAIC Classification: 722511
NAIC Description: Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
507 2017-11-01 MIKE HENNESSEY 2019-05-15

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
507	2017-11-01	MIKE HENNESSEY	2019-05-15

Plan Statistics for CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT PLAN

401k plan membership statisitcs for CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT PLAN

Measure Date Value
2017: CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year 2017-11-01 100
Total number of active participants reported on line 7a of the Form 5500 2017-11-01 107
Number of retired or separated participants receiving benefits 2017-11-01 1
Number of other retired or separated participants entitled to future benefits 2017-11-01 0
Total of all active and inactive participants 2017-11-01 108
Number of employers contributing to the scheme 2017-11-01 0

Measure	Date	Value
2017: CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT PLAN 2017 401k membership
Total participants, beginning-of-year	2017-11-01	100
Total number of active participants reported on line 7a of the Form 5500	2017-11-01	107
Number of retired or separated participants receiving benefits	2017-11-01	1
Number of other retired or separated participants entitled to future benefits	2017-11-01	0
Total of all active and inactive participants	2017-11-01	108
Number of employers contributing to the scheme	2017-11-01	0

Form 5500 Responses for CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT PLAN

2017: CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT PLAN 2017 form 5500 responses
2017-11-01	Type of plan entity	Single employer plan
2017-11-01	First time form 5500 has been submitted	Yes
2017-11-01	Plan funding arrangement – Insurance	Yes
2017-11-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

AVESIS INSURANCE INCORPORATED (National Association of Insurance Commissioners NAIC id number: 11163 )

Policy contract number

30781-1151

Policy instance

Insurance contract or identification number	30781-1151
Number of Individuals Covered	118
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $1,630
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $10,189
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

BLUE CROSS BLUE SHIELD OF ARIZONA (National Association of Insurance Commissioners NAIC id number: 53589 )

Policy contract number

27053

Policy instance

Insurance contract or identification number	27053
Number of Individuals Covered	102
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $30,015
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $601,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AMERICAN NATIONAL INSURANCE COMPANY OF TEXAS (National Association of Insurance Commissioners NAIC id number: 71773 )

Policy contract number

10005905

Policy instance

Insurance contract or identification number	10005905
Number of Individuals Covered	81
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $2,105
Total amount of fees paid to insurance company	USD $0
Dental Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $29,032
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

AFLAC (National Association of Insurance Commissioners NAIC id number: 60380 )

Policy contract number

DHD82

Policy instance

Insurance contract or identification number	DHD82
Number of Individuals Covered	21
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $4,780
Total amount of fees paid to insurance company	USD $80
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS, HOSPITAL, CANCER
Welfare Benefit Premiums Paid to Carrier	USD $28,579
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

702692

Policy instance

Insurance contract or identification number	702692
Number of Individuals Covered	34
Insurance policy start date	2017-11-01
Insurance policy end date	2018-10-31
Total amount of commissions paid to insurance broker	USD $2,899
Total amount of fees paid to insurance company	USD $181
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	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $14,493
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

Potentially related plans

CEO FOODS, INC. DBA EEGEE'S HEALTH & WELFARE BENEFIT PLAN [EIN = 364898087]

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Company Name:	CEO FOODS, INC. DBA EEGEES
Employer identification number (EIN):	953981762
NAIC Classification:	722511
NAIC Description:	Full-Service Restaurants