401k Plan data: BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN plan

BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN
Plan identification number	501

BLUEGRASS RESTAURANT HOLDINGS 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

BLUEGRASS RESTAURANT HOLDINGS has sponsored the creation of one or more 401k plans.

Company Name: BLUEGRASS RESTAURANT HOLDINGS

Employer identification number (EIN): 262740110

NAIC Classification: 722511
NAIC Description: Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-01-01 PATRICK CORRELL 2023-04-11
501 2021-01-01 PAT CORRELL 2022-04-01

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2022-01-01	PATRICK CORRELL	2023-04-11
501	2021-01-01	PAT CORRELL	2022-04-01

Plan Statistics for BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN

401k plan membership statisitcs for BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN

Measure Date Value
2022: BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 267
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 267
Number of retired or separated participants receiving benefits 2022-01-01 0
Number of other retired or separated participants entitled to future benefits 2022-01-01 0
Total of all active and inactive participants 2022-01-01 267
Number of employers contributing to the scheme 2022-01-01 0
2021: BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 219
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 267
Number of retired or separated participants receiving benefits 2021-01-01 0
Number of other retired or separated participants entitled to future benefits 2021-01-01 0
Total of all active and inactive participants 2021-01-01 267
Number of employers contributing to the scheme 2021-01-01 0

Measure	Date	Value
2022: BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	267
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	267
Number of retired or separated participants receiving benefits	2022-01-01	0
Number of other retired or separated participants entitled to future benefits	2022-01-01	0
Total of all active and inactive participants	2022-01-01	267
Number of employers contributing to the scheme	2022-01-01	0
2021: BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	219
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	267
Number of retired or separated participants receiving benefits	2021-01-01	0
Number of other retired or separated participants entitled to future benefits	2021-01-01	0
Total of all active and inactive participants	2021-01-01	267
Number of employers contributing to the scheme	2021-01-01	0

Form 5500 Responses for BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN

2022: BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN 2022 form 5500 responses
2022-01-01	Type of plan entity	Single employer plan
2022-01-01	Plan funding arrangement – Insurance	Yes
2022-01-01	Plan benefit arrangement – Insurance	Yes
2021: BLUEGRASS RESTAURANT HOLDINGS WELFARE BENEFIT PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	First time form 5500 has been submitted	Yes
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

W27957

Policy instance

Insurance contract or identification number	W27957
Number of Individuals Covered	214
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $38,401
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,232,089
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $38,401
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

248842

Policy instance

Insurance contract or identification number	248842
Number of Individuals Covered	267
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $6,366
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $44,604
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $6,366
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

ANTHEM HEALTH PLAN OF KENTUCKY D.B.A. ANTHEM BLUECROSS BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 95120 )

Policy contract number

W27957

Policy instance

Insurance contract or identification number	W27957
Number of Individuals Covered	186
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $47,304
Total amount of fees paid to insurance company	USD $2,673
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $1,244,761
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $47,304
Amount paid for insurance broker fees	2673
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

ANTHEM LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 61069 )

Policy contract number

248842

Policy instance

Insurance contract or identification number	248842
Number of Individuals Covered	543
Insurance policy start date	2021-01-01
Insurance policy end date	2021-12-31
Total amount of commissions paid to insurance broker	USD $7,304
Total amount of fees paid to insurance company	USD $78
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 $2,868
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,184
Amount paid for insurance broker fees	78
Additional information about fees paid to insurance broker	FEES
Insurance broker organization code?	3

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Company Name:	BLUEGRASS RESTAURANT HOLDINGS
Employer identification number (EIN):	262740110
NAIC Classification:	722511
NAIC Description:	Full-Service Restaurants