401k Plan data: BAGGER DAVE'S BURGER TAVERN 401(K) PLAN plan

BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 401k Plan overview

Plan Name	BAGGER DAVE'S BURGER TAVERN 401(K) PLAN
Plan identification number	001

BAGGER DAVE'S BURGER TAVERN 401(K) PLAN Benefits

401k Plan Type

Defined Contribution Pension

Plan Features/Benefits

Profit-sharing
ERISA section 404(c) Plan - This plan, or any part of it is intended to meet the conditions of 29 CFR 2550.404c-1.
Total participant-directed account plan - Participants have the opportunity to direct the investment of all the assets allocated to their individual accounts, regardless of whether 29 CFR 2550.404c-1 is intended to be met.
Code section 401(k) feature - A cash or deferred arrangement described in Code section 401(k) that is part of a qualified defined contribution plan that provides for an election by employees to defer part of their compensation or receive these amounts in cash.
Code section 401(m) arrangement - Employee contributions are allocated to separate accounts under the plan or employer contributions are based, in whole or in part, on employee deferrals or contribtions to the plan. Not applicable if plan is 401(k) plan with only QNECs and/or QMACs. Also not applicable if Code section 403(b)(1), 403(b)(7) or 408 arrangements/accounts/annuities.
Total or partial participant-directed account plan - plan uses default investment account for participants who fail to direct assets in their account.
Master plan - A pension plan that is made available by a sponsor for adoption by employers; that is the subject of a favorable opinion letter; and for which a single funding medium (for example, a trust or custodial account) is established for the joint use of all adopting employers.

401k Sponsoring company profile

BAGGER DAVE'S BURGER TAVERN has sponsored the creation of one or more 401k plans.

Company Name: BAGGER DAVE'S BURGER TAVERN

Employer identification number (EIN): 208639542

NAIC Classification: 551112
NAIC Description: Offices of Other Holding Companies

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BAGGER DAVE'S BURGER TAVERN 401(K) PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
001 2020-01-01
001 2019-01-01
001 2018-01-01

Plan Statistics for BAGGER DAVE'S BURGER TAVERN 401(K) PLAN

401k plan membership statisitcs for BAGGER DAVE'S BURGER TAVERN 401(K) PLAN

Measure Date Value
2020: BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 119
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 0
Number of retired or separated participants receiving benefits 2020-01-01 0
Number of other retired or separated participants entitled to future benefits 2020-01-01 0
Total of all active and inactive participants 2020-01-01 0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2020-01-01 0
Total participants 2020-01-01 0
Number of participants with account balances 2020-01-01 0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2020-01-01 0
2019: BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 157
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 134
Number of retired or separated participants receiving benefits 2019-01-01 2
Number of other retired or separated participants entitled to future benefits 2019-01-01 7
Total of all active and inactive participants 2019-01-01 143
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2019-01-01 0
Total participants 2019-01-01 143
Number of participants with account balances 2019-01-01 26
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2019-01-01 1
2018: BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year 2018-01-01 403
Total number of active participants reported on line 7a of the Form 5500 2018-01-01 156
Number of retired or separated participants receiving benefits 2018-01-01 2
Number of other retired or separated participants entitled to future benefits 2018-01-01 8
Total of all active and inactive participants 2018-01-01 166
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2018-01-01 0
Total participants 2018-01-01 166
Number of participants with account balances 2018-01-01 29
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested 2018-01-01 4

Measure	Date	Value
2020: BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	119
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	0
Number of retired or separated participants receiving benefits	2020-01-01	0
Number of other retired or separated participants entitled to future benefits	2020-01-01	0
Total of all active and inactive participants	2020-01-01	0
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2020-01-01	0
Total participants	2020-01-01	0
Number of participants with account balances	2020-01-01	0
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2020-01-01	0
2019: BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	157
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	134
Number of retired or separated participants receiving benefits	2019-01-01	2
Number of other retired or separated participants entitled to future benefits	2019-01-01	7
Total of all active and inactive participants	2019-01-01	143
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2019-01-01	0
Total participants	2019-01-01	143
Number of participants with account balances	2019-01-01	26
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2019-01-01	1
2018: BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2018 401k membership
Total participants, beginning-of-year	2018-01-01	403
Total number of active participants reported on line 7a of the Form 5500	2018-01-01	156
Number of retired or separated participants receiving benefits	2018-01-01	2
Number of other retired or separated participants entitled to future benefits	2018-01-01	8
Total of all active and inactive participants	2018-01-01	166
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2018-01-01	0
Total participants	2018-01-01	166
Number of participants with account balances	2018-01-01	29
Participants that terminated employment during the plan year with accrued benefits that were less than 100% vested	2018-01-01	4

Financial Data on BAGGER DAVE'S BURGER TAVERN 401(K) PLAN

Measure	Date	Value
2020 : BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2020 401k financial data
Total unrealized appreciation/depreciation of assets	2020-11-30	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-11-30	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2020-11-30	$0
Total income from all sources (including contributions)	2020-11-30	$39,837
Total loss/gain on sale of assets	2020-11-30	$0
Total of all expenses incurred	2020-11-30	$472,226
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2020-11-30	$463,025
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2020-11-30	$34,754
Value of total assets at end of year	2020-11-30	$0
Value of total assets at beginning of year	2020-11-30	$432,389
Total of administrative expenses incurred including professional, contract, advisory and management fees	2020-11-30	$9,201
Total interest from all sources	2020-11-30	$0
Total dividends received (eg from common stock, registered investment company shares)	2020-11-30	$0
Has a resolution to terminate the plan been adopted during the plan year or any prior plan year	2020-11-30	No
Was this plan covered by a fidelity bond	2020-11-30	Yes
Value of fidelity bond cover	2020-11-30	$500,000
If this is an individual account plan, was there a blackout period	2020-11-30	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2020-11-30	$0
Were there any nonexempt tranactions with any party-in-interest	2020-11-30	No
Contributions received from participants	2020-11-30	$34,754
Participant contributions at beginning of year	2020-11-30	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-11-30	No
Value of net income/loss	2020-11-30	$-432,389
Value of net assets at end of year (total assets less liabilities)	2020-11-30	$0
Value of net assets at beginning of year (total assets less liabilities)	2020-11-30	$432,389
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2020-11-30	No
Were any loans by the plan or fixed income obligations due to the plan in default	2020-11-30	No
Were any leases to which the plan was party in default or uncollectible	2020-11-30	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2020-11-30	$0
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2020-11-30	$424,574
Interest on participant loans	2020-11-30	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2020-11-30	$0
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2020-11-30	$382
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2020-11-30	$382
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2020-11-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2020-11-30	$0
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2020-11-30	$5,501
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2020-11-30	$5,083
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2020-11-30	No
Was there a failure to transmit to the plan any participant contributions	2020-11-30	No
Has the plan failed to provide any benefit when due under the plan	2020-11-30	No
Employer contributions (assets) at end of year	2020-11-30	$0
Employer contributions (assets) at beginning of year	2020-11-30	$1,932
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2020-11-30	$463,025
Contract administrator fees	2020-11-30	$9,201
Did the plan have assets held for investment	2020-11-30	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2020-11-30	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2020-11-30	No
Opinion of an independent qualified public accountant for this plan	2020-11-30	Disclaimer
Accountancy firm name	2020-11-30	PLANTE MORAN, PLLC
Accountancy firm EIN	2020-11-30	381357951
2019 : BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2019 401k financial data
Total unrealized appreciation/depreciation of assets	2019-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2019-12-31	$0
Total income from all sources (including contributions)	2019-12-31	$128,657
Total loss/gain on sale of assets	2019-12-31	$0
Total of all expenses incurred	2019-12-31	$21,757
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2019-12-31	$15,030
Expenses. Certain deemed distributions of participant loans	2019-12-31	$0
Value of total corrective distributions	2019-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2019-12-31	$46,676
Value of total assets at end of year	2019-12-31	$432,389
Value of total assets at beginning of year	2019-12-31	$325,489
Total of administrative expenses incurred including professional, contract, advisory and management fees	2019-12-31	$6,727
Total interest from all sources	2019-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2019-12-31	$0
Was this plan covered by a fidelity bond	2019-12-31	Yes
Value of fidelity bond cover	2019-12-31	$3,000,000
If this is an individual account plan, was there a blackout period	2019-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2019-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2019-12-31	No
Contributions received from participants	2019-12-31	$46,676
Participant contributions at end of year	2019-12-31	$0
Income. Received or receivable in cash from other sources (including rollovers)	2019-12-31	$0
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Value of net income/loss	2019-12-31	$106,900
Value of net assets at end of year (total assets less liabilities)	2019-12-31	$432,389
Value of net assets at beginning of year (total assets less liabilities)	2019-12-31	$325,489
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2019-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2019-12-31	No
Were any leases to which the plan was party in default or uncollectible	2019-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2019-12-31	$424,574
Value of interest in registered invesment companies (eg mutual funds) at beginning of year	2019-12-31	$318,752
Interest on participant loans	2019-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2019-12-31	$382
Interest-bearing cash (include money market accounts & certificates of deposit) at beginning of the Year	2019-12-31	$280
Value of interest bearing cash (including money market accounts and certificates of deposits) at beginning of year	2019-12-31	$280
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2019-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2019-12-31	$5,501
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2019-12-31	$4,765
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2019-12-31	$81,981
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2019-12-31	No
Was there a failure to transmit to the plan any participant contributions	2019-12-31	No
Has the plan failed to provide any benefit when due under the plan	2019-12-31	No
Contributions received in cash from employer	2019-12-31	$0
Employer contributions (assets) at end of year	2019-12-31	$1,932
Employer contributions (assets) at beginning of year	2019-12-31	$1,692
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2019-12-31	$15,030
Contract administrator fees	2019-12-31	$6,727
Did the plan have assets held for investment	2019-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2019-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2019-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2019-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2019-12-31	Disclaimer
Accountancy firm name	2019-12-31	PLANTE MORAN, PLLC
Accountancy firm EIN	2019-12-31	381357951
2018 : BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2018 401k financial data
Total unrealized appreciation/depreciation of assets	2018-12-31	$0
Total liabilities at end of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total liabilities at beginning of year (benefit claims payable, operating payabales, acquisition indebtedness and other liabilities)	2018-12-31	$0
Total income from all sources (including contributions)	2018-12-31	$429,420
Total loss/gain on sale of assets	2018-12-31	$0
Total of all expenses incurred	2018-12-31	$103,931
Benefit payments and payments to participlants,beneficiaries,insurance carriers and others	2018-12-31	$98,831
Expenses. Certain deemed distributions of participant loans	2018-12-31	$0
Value of total corrective distributions	2018-12-31	$0
Total contributions o plan (from employers,participants, others, non cash contrinutions)	2018-12-31	$453,647
Value of total assets at end of year	2018-12-31	$325,489
Value of total assets at beginning of year	2018-12-31	$0
Total of administrative expenses incurred including professional, contract, advisory and management fees	2018-12-31	$5,100
Total interest from all sources	2018-12-31	$0
Total dividends received (eg from common stock, registered investment company shares)	2018-12-31	$0
Was this plan covered by a fidelity bond	2018-12-31	Yes
Value of fidelity bond cover	2018-12-31	$500,000
If this is an individual account plan, was there a blackout period	2018-12-31	No
Total value of distributions paid in property other than in cash, annuity contracts, or publicly traded employer securities	2018-12-31	$0
Were there any nonexempt tranactions with any party-in-interest	2018-12-31	No
Contributions received from participants	2018-12-31	$51,368
Participant contributions at end of year	2018-12-31	$0
Participant contributions at end of year	2018-12-31	$1,692
Income. Received or receivable in cash from other sources (including rollovers)	2018-12-31	$402,279
Did the receive any noncash contributions whose value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Value of net income/loss	2018-12-31	$325,489
Value of net assets at end of year (total assets less liabilities)	2018-12-31	$325,489
Value of net assets at beginning of year (total assets less liabilities)	2018-12-31	$0
Did the plan have a loss casued by fraud or dishonesty (regardless whether reimbursed by fidelity bond)	2018-12-31	No
Were any loans by the plan or fixed income obligations due to the plan in default	2018-12-31	No
Were any leases to which the plan was party in default or uncollectible	2018-12-31	No
Value of interest in registered invesment companies (eg mutual funds) at end of year	2018-12-31	$318,752
Interest on participant loans	2018-12-31	$0
Value of interest bearing cash (including money market accounts and certificates of deposits) at end of year	2018-12-31	$280
Interest earned from interest bearing cash (including money market accounts and certificates of deposit)	2018-12-31	$0
Value of funds held in insurance company general accounts (unallocated contracts) at end of year	2018-12-31	$4,765
Value of funds held in insurance company general accounts (unallocated contracts) at beginning of year	2018-12-31	$0
Net investment gain/loss from registered investment companies (e.g. mutual funds)	2018-12-31	$-24,227
Were any plan transactions or series of transactions in excess of 5% of the current value of the plan assets	2018-12-31	No
Was there a failure to transmit to the plan any participant contributions	2018-12-31	No
Has the plan failed to provide any benefit when due under the plan	2018-12-31	No
Contributions received in cash from employer	2018-12-31	$0
Benefit payments and payments to provide benefits directly to participlants or beneficiaries including direct rollovers	2018-12-31	$98,831
Contract administrator fees	2018-12-31	$5,100
Did the plan have assets held for investment	2018-12-31	Yes
Did the plan hold any assets whose current value was neither redily determinable on an established market nor set by an independent third party appraiser	2018-12-31	No
Were all the plan assets eitehr distributed to particpants/beneficiaries, transferred to another plan or brought under the control of the PBGC	2018-12-31	No
Accountant perfomed limited scope audit pursuant to 29 CFR 2520.103-8 and/or 103-12(d)	2018-12-31	Yes
Opinion of an independent qualified public accountant for this plan	2018-12-31	Disclaimer
Accountancy firm name	2018-12-31	PLANTE MORAN, PLLC
Accountancy firm EIN	2018-12-31	381357951

Form 5500 Responses for BAGGER DAVE'S BURGER TAVERN 401(K) PLAN

2020: BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Submission has been amended	No
2020-01-01	This submission is the final filing	Yes
2020-01-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2020-01-01	Plan is a collectively bargained plan	No
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan funding arrangement – Trust	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement - Trust	Yes
2019: BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	Submission has been amended	No
2019-01-01	This submission is the final filing	No
2019-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-01-01	Plan is a collectively bargained plan	No
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan funding arrangement – Trust	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2018: BAGGER DAVE'S BURGER TAVERN 401(K) PLAN 2018 form 5500 responses
2018-01-01	Type of plan entity	Single employer plan
2018-01-01	Submission has been amended	No
2018-01-01	This submission is the final filing	No
2018-01-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-01-01	Plan is a collectively bargained plan	No
2018-01-01	Plan funding arrangement – Insurance	Yes
2018-01-01	Plan funding arrangement – Trust	Yes
2018-01-01	Plan benefit arrangement – Insurance	Yes
2018-01-01	Plan benefit arrangement - Trust	Yes

Insurance Providers Used on plan

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

GAP-CP-KR9M

Policy instance

Insurance contract or identification number	GAP-CP-KR9M
Number of Individuals Covered	0
Insurance policy start date	2020-01-01
Insurance policy end date	2020-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

GAP-CP-KR9M

Policy instance

Insurance contract or identification number	GAP-CP-KR9M
Number of Individuals Covered	143
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

GAP-CP-KR9M

Policy instance

Insurance contract or identification number	GAP-CP-KR9M
Number of Individuals Covered	166
Insurance policy start date	2018-01-01
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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 plan	No
Contracts With Unallocated Funds Deposit Administration	0
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 Benefit	No
Dental Insurance Welfare Benefit	No
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No

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Company Name:	BAGGER DAVE'S BURGER TAVERN
Employer identification number (EIN):	208639542
NAIC Classification:	551112
NAIC Description:	Offices of Other Holding Companies