401k Plan data: CHICKIE'S AND PETE'S WELFARE BENEFIT PLAN plan

CHICKIE'S AND PETE'S WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	CHICKIE'S AND PETE'S WELFARE BENEFIT PLAN
Plan identification number	501

CHICKIE'S AND PETE'S WELFARE BENEFIT PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Temporary disability (accident and sickness) Long-term disability cover Other welfare benefit cover

401k Sponsoring company profile

CHICKIE'S AND PETE'S has sponsored the creation of one or more 401k plans.

Company Name: CHICKIE'S AND PETE'S

Employer identification number (EIN): 232979978

NAIC Classification: 722511
NAIC Description: Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan CHICKIE'S AND PETE'S WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-03-01 JAHANGIR NASIR 2024-09-03
501 2020-03-01 NIKI BOUNDS 2021-07-08
501 2019-03-01 NIKI BOUNDS 2020-07-12
501 2018-03-01 NIKI BOUNDS 2019-09-17

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2023-03-01	JAHANGIR NASIR	2024-09-03
501	2020-03-01	NIKI BOUNDS	2021-07-08
501	2019-03-01	NIKI BOUNDS	2020-07-12
501	2018-03-01	NIKI BOUNDS	2019-09-17

Form 5500 Responses for CHICKIE'S AND PETE'S WELFARE BENEFIT PLAN

2023: CHICKIE'S AND PETE'S WELFARE BENEFIT PLAN 2023 form 5500 responses
2023-03-01	Type of plan entity	Single employer plan
2023-03-01	Submission has been amended	No
2023-03-01	This submission is the final filing	No
2023-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2023-03-01	Plan is a collectively bargained plan	No
2023-03-01	Plan funding arrangement – Insurance	Yes
2023-03-01	Plan benefit arrangement – Insurance	Yes
2020: CHICKIE'S AND PETE'S WELFARE BENEFIT PLAN 2020 form 5500 responses
2020-03-01	Type of plan entity	Single employer plan
2020-03-01	Submission has been amended	No
2020-03-01	This submission is the final filing	No
2020-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2020-03-01	Plan is a collectively bargained plan	No
2020-03-01	Plan funding arrangement – Insurance	Yes
2020-03-01	Plan benefit arrangement – Insurance	Yes
2019: CHICKIE'S AND PETE'S WELFARE BENEFIT PLAN 2019 form 5500 responses
2019-03-01	Type of plan entity	Single employer plan
2019-03-01	Submission has been amended	No
2019-03-01	This submission is the final filing	No
2019-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2019-03-01	Plan is a collectively bargained plan	No
2019-03-01	Plan funding arrangement – Insurance	Yes
2019-03-01	Plan benefit arrangement – Insurance	Yes
2018: CHICKIE'S AND PETE'S WELFARE BENEFIT PLAN 2018 form 5500 responses
2018-03-01	Type of plan entity	Single employer plan
2018-03-01	First time form 5500 has been submitted	Yes
2018-03-01	Submission has been amended	No
2018-03-01	This submission is the final filing	No
2018-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2018-03-01	Plan is a collectively bargained plan	No
2018-03-01	Plan funding arrangement – Insurance	Yes
2018-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )

Policy contract number

0034287

Policy instance

Insurance contract or identification number	0034287
Number of Individuals Covered	87
Insurance policy start date	2023-03-01
Insurance policy end date	2024-02-29
Total amount of commissions paid to insurance broker	USD $7,393
Total amount of fees paid to insurance company	USD $3,155
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	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 & DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $54,860
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )

Policy contract number

9524

Policy instance

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

9524

Policy instance

AMERIHEALTH HMO, INC. (National Association of Insurance Commissioners NAIC id number: 95044 )

Policy contract number

9524

Policy instance

AMERIHEALTH HMO, INC. (National Association of Insurance Commissioners NAIC id number: 95044 )

Policy contract number

9524

Policy instance

KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )

Policy contract number

9524

Policy instance

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

9524

Policy instance

INDEPENDENCE BLUE CROSS (National Association of Insurance Commissioners NAIC id number: 93688 )

Policy contract number

9524

Policy instance

AMERIHEALTH HMO, INC. (National Association of Insurance Commissioners NAIC id number: 95044 )

Policy contract number

9524

Policy instance

KEYSTONE HEALTH PLAN EAST (National Association of Insurance Commissioners NAIC id number: 95056 )

Policy contract number

9524

Policy instance

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Company Name:	CHICKIE'S AND PETE'S
Employer identification number (EIN):	232979978
NAIC Classification:	722511
NAIC Description:	Full-Service Restaurants