401k Plan data: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN plan

MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 401k Plan overview

Plan Name	MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN
Plan identification number	501

MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN Benefits

401k Plan Type

Welfare Benefit

Plan Features/Benefits

Health (other than dental or vision)
Life insurance
Dental
Vision
Long-term disability cover
Death benefits (include travel accident but not life insurance)
Unfunded, fully insured, or combination unfunded/insured welfare plan that will not file a Form 5500 for next plan year pursuant to 29 CFR 2520.104-20.
Unfunded, fully insured, or combination unfunded/insured welfare plan that stopped filing form 5500s in an earlier plan year pursuant to 29 CFR 2520.104-20.

401k Sponsoring company profile

MISSOURI JACK LLC has sponsored the creation of one or more 401k plans.

Company Name: MISSOURI JACK LLC

Employer identification number (EIN): 452037521

NAIC Classification: 722513
NAIC Description: Limited-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2023-01-01 HAMID SHARAFATIAN 2024-09-06
501 2022-01-01 HAMID SHARAFATIAN 2023-09-13
501 2021-01-01 HAMID SHARAFATIAN 2022-09-28
501 2020-01-01 HAMID SHARAFATIAN 2021-10-14
501 2019-01-01 HAMID SHARAFATIAN 2020-10-13

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed
501	2023-01-01	HAMID SHARAFATIAN	2024-09-06
501	2022-01-01	HAMID SHARAFATIAN	2023-09-13
501	2021-01-01	HAMID SHARAFATIAN	2022-09-28
501	2020-01-01	HAMID SHARAFATIAN	2021-10-14
501	2019-01-01	HAMID SHARAFATIAN	2020-10-13

Plan Statistics for MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN

401k plan membership statisitcs for MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN

Measure Date Value
2023: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year 2023-01-01 72
Total number of active participants reported on line 7a of the Form 5500 2023-01-01 834
Number of retired or separated participants receiving benefits 2023-01-01 0
Number of other retired or separated participants entitled to future benefits 2023-01-01 0
Total of all active and inactive participants 2023-01-01 834
Number of employers contributing to the scheme 2023-01-01 0
2022: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year 2022-01-01 190
Total number of active participants reported on line 7a of the Form 5500 2022-01-01 72
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 72
Number of employers contributing to the scheme 2022-01-01 0
2021: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year 2021-01-01 218
Total number of active participants reported on line 7a of the Form 5500 2021-01-01 190
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 2021-01-01 190
Number of employers contributing to the scheme 2021-01-01 0
2020: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year 2020-01-01 217
Total number of active participants reported on line 7a of the Form 5500 2020-01-01 218
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 2020-01-01 218
Number of employers contributing to the scheme 2020-01-01 0
2019: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 100
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 217
Number of retired or separated participants receiving benefits 2019-01-01 0
Number of other retired or separated participants entitled to future benefits 2019-01-01 0
Total of all active and inactive participants 2019-01-01 217
Number of employers contributing to the scheme 2019-01-01 0

Measure	Date	Value
2023: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2023 401k membership
Total participants, beginning-of-year	2023-01-01	72
Total number of active participants reported on line 7a of the Form 5500	2023-01-01	834
Number of retired or separated participants receiving benefits	2023-01-01	0
Number of other retired or separated participants entitled to future benefits	2023-01-01	0
Total of all active and inactive participants	2023-01-01	834
Number of employers contributing to the scheme	2023-01-01	0
2022: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2022 401k membership
Total participants, beginning-of-year	2022-01-01	190
Total number of active participants reported on line 7a of the Form 5500	2022-01-01	72
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	72
Number of employers contributing to the scheme	2022-01-01	0
2021: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2021 401k membership
Total participants, beginning-of-year	2021-01-01	218
Total number of active participants reported on line 7a of the Form 5500	2021-01-01	190
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	190
Number of employers contributing to the scheme	2021-01-01	0
2020: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2020 401k membership
Total participants, beginning-of-year	2020-01-01	217
Total number of active participants reported on line 7a of the Form 5500	2020-01-01	218
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	218
Number of employers contributing to the scheme	2020-01-01	0
2019: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	100
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	217
Number of retired or separated participants receiving benefits	2019-01-01	0
Number of other retired or separated participants entitled to future benefits	2019-01-01	0
Total of all active and inactive participants	2019-01-01	217
Number of employers contributing to the scheme	2019-01-01	0

Form 5500 Responses for MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN

2023: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2023 form 5500 responses
2023-01-01	Type of plan entity	Single employer plan
2023-01-01	Plan funding arrangement – Insurance	Yes
2023-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2023-01-01	Plan benefit arrangement – Insurance	Yes
2023-01-01	Plan benefit arrangement – General assets of the sponsor	Yes
2022: MISSOURI JACK EMPLOYEE HEALTH & WELFARE 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: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2021 form 5500 responses
2021-01-01	Type of plan entity	Single employer plan
2021-01-01	Plan funding arrangement – Insurance	Yes
2021-01-01	Plan benefit arrangement – Insurance	Yes
2020: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2020 form 5500 responses
2020-01-01	Type of plan entity	Single employer plan
2020-01-01	Plan funding arrangement – Insurance	Yes
2020-01-01	Plan benefit arrangement – Insurance	Yes
2019: MISSOURI JACK EMPLOYEE HEALTH & WELFARE PLAN 2019 form 5500 responses
2019-01-01	Type of plan entity	Single employer plan
2019-01-01	First time form 5500 has been submitted	Yes
2019-01-01	Plan funding arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

W61493

Policy instance

Insurance contract or identification number	W61493
Number of Individuals Covered	0
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,998
Total amount of fees paid to insurance company	USD $1,109
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $4,742
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10248731

Policy instance

Insurance contract or identification number	10248731
Number of Individuals Covered	834
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $2,787
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $18,569
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

W61493

Policy instance

Insurance contract or identification number	W61493
Number of Individuals Covered	202
Insurance policy start date	2023-01-01
Insurance policy end date	2023-12-31
Total amount of commissions paid to insurance broker	USD $8,998
Total amount of fees paid to insurance company	USD $1,109
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $36,518
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

W61493

Policy instance

Insurance contract or identification number	W61493
Number of Individuals Covered	0
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $30,401
Total amount of fees paid to insurance company	USD $1,138
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $8,175
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10248731

Policy instance

Insurance contract or identification number	10248731
Number of Individuals Covered	0
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $1,281
Total amount of fees paid to insurance company	USD $0
Life Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $8,542
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

W61493

Policy instance

Insurance contract or identification number	W61493
Number of Individuals Covered	136
Insurance policy start date	2022-01-01
Insurance policy end date	2022-12-31
Total amount of commissions paid to insurance broker	USD $30,401
Total amount of fees paid to insurance company	USD $1,138
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Welfare Benefit Premiums Paid to Carrier	USD $765,336
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10248731

Policy instance

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

Policy contract number

W61493

Policy instance

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

W61493

Policy instance

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

Policy contract number

W61493

Policy instance

THE LINCOLN NATIONAL LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65676 )

Policy contract number

10248731

Policy instance

HEALTHY ALLIANCE LIFE INSURANCE COMPANY (G0262) (National Association of Insurance Commissioners NAIC id number: 78972 )

Policy contract number

W61493

Policy instance

Potentially related plans

MISSOURI JACK, LLC 401(K) PLAN [EIN = 452037527]

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Company Name:	MISSOURI JACK LLC
Employer identification number (EIN):	452037521
NAIC Classification:	722513
NAIC Description:	Limited-Service Restaurants