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EMPLOYEE BENEFITS PLAN 401k Plan overview

Plan NameEMPLOYEE BENEFITS PLAN
Plan identification number 501

EMPLOYEE BENEFITS PLAN Benefits

401k Plan TypeWelfare Benefit
Plan Features/Benefits
  • Health (other than dental or vision)
  • Life insurance
  • Dental
  • Vision
  • Temporary disability (accident and sickness)
  • Long-term disability cover
  • Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

ROCK SOLID RESTAURANTS LLC has sponsored the creation of one or more 401k plans.

Company Name:ROCK SOLID RESTAURANTS LLC
Employer identification number (EIN):462371003
NAIC Classification:722511
NAIC Description:Full-Service Restaurants

Additional information about ROCK SOLID RESTAURANTS LLC

Jurisdiction of Incorporation: Oregon Secretary of State Corporations Division
Incorporation Date: 2016-01-15
Company Identification Number: 117841692
Legal Registered Office Address: 17155 SE SUNNYSIDE RD

HAPPY VALLEY
United States of America (USA)
97086

More information about ROCK SOLID RESTAURANTS LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan EMPLOYEE BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator SignedName of Company SponsorDate Sponsor Signed
5012021-10-01TOMMY TRIBBETT2023-01-10
5012020-12-01TOMMY TRIBBETT2022-01-18
5012019-12-01THOMAS H. TRIBBETT2021-06-01
5012019-12-01THOMAS H. TRIBBETT2021-05-28
5012018-12-01THOMAS H. TRIBBETT2020-09-08
5012018-12-01THOMAS H. TRIBBETT2021-05-28

Plan Statistics for EMPLOYEE BENEFITS PLAN

401k plan membership statisitcs for EMPLOYEE BENEFITS PLAN

Measure Date Value
2021: EMPLOYEE BENEFITS PLAN 2021 401k membership
Total participants, beginning-of-year2021-10-01295
Total number of active participants reported on line 7a of the Form 55002021-10-01228
Number of retired or separated participants receiving benefits2021-10-010
Number of other retired or separated participants entitled to future benefits2021-10-010
Total of all active and inactive participants2021-10-01228
Number of employers contributing to the scheme2021-10-010
2020: EMPLOYEE BENEFITS PLAN 2020 401k membership
Total participants, beginning-of-year2020-12-01171
Total number of active participants reported on line 7a of the Form 55002020-12-01139
Number of retired or separated participants receiving benefits2020-12-010
Number of other retired or separated participants entitled to future benefits2020-12-010
Total of all active and inactive participants2020-12-01139
Number of employers contributing to the scheme2020-12-010
2019: EMPLOYEE BENEFITS PLAN 2019 401k membership
Total participants, beginning-of-year2019-12-01166
Total number of active participants reported on line 7a of the Form 55002019-12-01175
Number of retired or separated participants receiving benefits2019-12-010
Number of other retired or separated participants entitled to future benefits2019-12-010
Total of all active and inactive participants2019-12-01175
Number of employers contributing to the scheme2019-12-010
2018: EMPLOYEE BENEFITS PLAN 2018 401k membership
Total participants, beginning-of-year2018-12-01110
Total number of active participants reported on line 7a of the Form 55002018-12-01154
Number of retired or separated participants receiving benefits2018-12-010
Number of other retired or separated participants entitled to future benefits2018-12-010
Total of all active and inactive participants2018-12-01154
Number of employers contributing to the scheme2018-12-010

Form 5500 Responses for EMPLOYEE BENEFITS PLAN

2021: EMPLOYEE BENEFITS PLAN 2021 form 5500 responses
2021-10-01Type of plan entitySingle employer plan
2021-10-01Plan funding arrangement – InsuranceYes
2021-10-01Plan benefit arrangement – InsuranceYes
2020: EMPLOYEE BENEFITS PLAN 2020 form 5500 responses
2020-12-01Type of plan entitySingle employer plan
2020-12-01This return/report is a short plan year return/report (less than 12 months)Yes
2020-12-01Plan funding arrangement – InsuranceYes
2020-12-01Plan benefit arrangement – InsuranceYes
2019: EMPLOYEE BENEFITS PLAN 2019 form 5500 responses
2019-12-01Type of plan entitySingle employer plan
2019-12-01Submission has been amendedYes
2019-12-01Plan funding arrangement – InsuranceYes
2019-12-01Plan benefit arrangement – InsuranceYes
2018: EMPLOYEE BENEFITS PLAN 2018 form 5500 responses
2018-12-01Type of plan entitySingle employer plan
2018-12-01First time form 5500 has been submittedYes
2018-12-01Submission has been amendedYes
2018-12-01Plan funding arrangement – InsuranceYes
2018-12-01Plan benefit arrangement – InsuranceYes

Insurance Providers Used on plan

THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number554419
Policy instance 1
Insurance contract or identification number554419
Number of Individuals Covered234
Insurance policy start date2020-12-01
Insurance policy end date2021-11-30
Total amount of commissions paid to insurance brokerUSD $15,003
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $194,657
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $15,003
Amount paid for insurance broker fees0
Insurance broker organization code?3
REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )
Policy contract number10044035
Policy instance 2
Insurance contract or identification number10044035
Number of Individuals Covered265
Insurance policy start date2021-10-01
Insurance policy end date2022-09-30
Total amount of commissions paid to insurance brokerUSD $53,958
Total amount of fees paid to insurance companyUSD $3,960
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $1,111,563
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $53,958
Amount paid for insurance broker fees3960
Additional information about fees paid to insurance brokerBONUS
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number554419
Policy instance 1
Insurance contract or identification number554419
Number of Individuals Covered139
Insurance policy start date2020-12-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $0
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )
Policy contract number10044035
Policy instance 2
Insurance contract or identification number10044035
Number of Individuals Covered246
Insurance policy start date2020-10-01
Insurance policy end date2021-09-30
Total amount of commissions paid to insurance brokerUSD $44,176
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $939,183
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $44,176
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number554419
Policy instance 1
Insurance contract or identification number554419
Number of Individuals Covered181
Insurance policy start date2019-12-01
Insurance policy end date2020-11-30
Total amount of commissions paid to insurance brokerUSD $12,255
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $154,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,255
Amount paid for insurance broker fees0
Insurance broker organization code?3
REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )
Policy contract number10044035
Policy instance 2
Insurance contract or identification number10044035
Number of Individuals Covered246
Insurance policy start date2019-11-01
Insurance policy end date2020-09-30
Total amount of commissions paid to insurance brokerUSD $30,242
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $665,353
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $30,242
Amount paid for insurance broker fees0
Insurance broker organization code?3
THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 64246 )
Policy contract number554419
Policy instance 2
Insurance contract or identification number554419
Number of Individuals Covered167
Insurance policy start date2018-12-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $12,019
Total amount of fees paid to insurance companyUSD $0
Dental Insurance Welfare BenefitYes
Vision Insurance Welfare BenefitYes
Life Insurance Welfare BenefitYes
Temporary Disability Insurance Welfare BenefitYes
Long Term Disability Insurance Welfare BenefitYes
Other welfare benefits providedACCIDENTAL DEATH AND DISMEMBERMENT, ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to CarrierUSD $164,987
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $12,019
Amount paid for insurance broker fees0
Insurance broker organization code?3
GROUP HEALTH OPTIONS, INC. (National Association of Insurance Commissioners NAIC id number: 47055 )
Policy contract number6549000
Policy instance 1
Insurance contract or identification number6549000
Number of Individuals Covered213
Insurance policy start date2018-12-01
Insurance policy end date2019-10-31
Total amount of commissions paid to insurance brokerUSD $36,368
Total amount of fees paid to insurance companyUSD $5
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $779,414
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?Yes
Commission paid to Insurance BrokerUSD $36,368
Amount paid for insurance broker fees5
Additional information about fees paid to insurance brokerNON-MONETARY COMPENSATION
Insurance broker organization code?3
REGENCE BLUESHIELD (National Association of Insurance Commissioners NAIC id number: 53902 )
Policy contract number10044035
Policy instance 3
Insurance contract or identification number10044035
Number of Individuals Covered273
Insurance policy start date2019-11-01
Insurance policy end date2019-11-30
Total amount of commissions paid to insurance brokerUSD $3,292
Total amount of fees paid to insurance companyUSD $0
Health Insurance Welfare BenefitYes
Welfare Benefit Premiums Paid to CarrierUSD $67,169
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?No
Commission paid to Insurance BrokerUSD $3,292
Amount paid for insurance broker fees0
Insurance broker organization code?3

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