401k Plan data: LEGACY RESTAURANT GROUP EMPLOYEE BENEFITS PLAN plan

LEGACY RESTAURANT GROUP EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan Name	LEGACY RESTAURANT GROUP EMPLOYEE BENEFITS PLAN
Plan identification number	501

LEGACY RESTAURANT GROUP EMPLOYEE BENEFITS PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Life insurance Dental Vision Other welfare benefit cover

401k Sponsoring company profile

LEGACY RESTAURANT GROUP, L.L.C. has sponsored the creation of one or more 401k plans.

Company Name: LEGACY RESTAURANT GROUP, L.L.C.

Employer identification number (EIN): 431824787

NAIC Classification: 722513
NAIC Description: Limited-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan LEGACY RESTAURANT GROUP EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2022-05-01

Plan Statistics for LEGACY RESTAURANT GROUP EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for LEGACY RESTAURANT GROUP EMPLOYEE BENEFITS PLAN

Measure Date Value
2022: LEGACY RESTAURANT GROUP EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year 2022-05-01 109
Total number of active participants reported on line 7a of the Form 5500 2022-05-01 119
Number of retired or separated participants receiving benefits 2022-05-01 0
Number of other retired or separated participants entitled to future benefits 2022-05-01 0
Total of all active and inactive participants 2022-05-01 119

Measure	Date	Value
2022: LEGACY RESTAURANT GROUP EMPLOYEE BENEFITS PLAN 2022 401k membership
Total participants, beginning-of-year	2022-05-01	109
Total number of active participants reported on line 7a of the Form 5500	2022-05-01	119
Number of retired or separated participants receiving benefits	2022-05-01	0
Number of other retired or separated participants entitled to future benefits	2022-05-01	0
Total of all active and inactive participants	2022-05-01	119

Form 5500 Responses for LEGACY RESTAURANT GROUP EMPLOYEE BENEFITS PLAN

2022: LEGACY RESTAURANT GROUP EMPLOYEE BENEFITS PLAN 2022 form 5500 responses
2022-05-01	Type of plan entity	Single employer plan
2022-05-01	First time form 5500 has been submitted	Yes
2022-05-01	Plan funding arrangement – Insurance	Yes
2022-05-01	Plan funding arrangement – General assets of the sponsor	Yes
2022-05-01	Plan benefit arrangement – Insurance	Yes
2022-05-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

BLUE CROSS AND BLUE SHIELD OF KANSAS CITY (National Association of Insurance Commissioners NAIC id number: 47171 )

Policy contract number

45005000

Policy instance

Insurance contract or identification number	45005000
Number of Individuals Covered	155
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $45,799
Total amount of fees paid to insurance company	USD $18,458
Health Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $915,978
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $45,799
Amount paid for insurance broker fees	18458
Additional information about fees paid to insurance broker	ADMINISTRATIVE SERVICES OTHER NON-MONETARY COMPENSATION
Insurance broker organization code?	3

EYEMED VISION CARE (National Association of Insurance Commissioners NAIC id number: 71870 )

Policy contract number

10371971001, 02

Policy instance

Insurance contract or identification number	10371971001, 02
Number of Individuals Covered	168
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $1,090
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $13,344
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $1,090
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

170123

Policy instance

Insurance contract or identification number	170123
Number of Individuals Covered	132
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $4,308
Life Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,308
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

170123

Policy instance

Insurance contract or identification number	170123
Number of Individuals Covered	119
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $3,094
Dental Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,094
Insurance broker organization code?	3

STANDARD INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 69019 )

Policy contract number

170123

Policy instance

Insurance contract or identification number	170123
Number of Individuals Covered	81
Insurance policy start date	2022-05-01
Insurance policy end date	2023-04-30
Total amount of commissions paid to insurance broker	USD $4,695
Other welfare benefits provided	AD&D, ACCIDENT, CI, EAP
Welfare Benefit Premiums Paid to Carrier	USD $20,909
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $4,695
Insurance broker organization code?	3

Potentially related plans

LEGACY RESTAURANT GROUP LTD 401 K PROFIT SHARING PLAN TRUST [EIN = 752946040]

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Company Name:	LEGACY RESTAURANT GROUP, L.L.C.
Employer identification number (EIN):	431824787
NAIC Classification:	722513
NAIC Description:	Limited-Service Restaurants