401k Plan data: PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN plan

PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN
Plan identification number	501

PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN Benefits

401k Plan Type	Welfare Benefit
Plan Features/Benefits	Health (other than dental or vision) Dental Vision

401k Sponsoring company profile

PERRY'S LARKSPUR, LLC has sponsored the creation of one or more 401k plans.

Company Name: PERRY'S LARKSPUR, LLC

Employer identification number (EIN): 473336554

NAIC Classification: 722511
NAIC Description: Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2019-01-01 MARGARET BUTLER 2020-10-06

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2019-01-01	MARGARET BUTLER	2020-10-06

Plan Statistics for PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN

401k plan membership statisitcs for PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN

Measure Date Value
2019: PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year 2019-01-01 9
Total number of active participants reported on line 7a of the Form 5500 2019-01-01 8
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 8
Number of employers contributing to the scheme 2019-01-01 0

Measure	Date	Value
2019: PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN 2019 401k membership
Total participants, beginning-of-year	2019-01-01	9
Total number of active participants reported on line 7a of the Form 5500	2019-01-01	8
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	8
Number of employers contributing to the scheme	2019-01-01	0

Financial Data on PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN

Measure	Date	Value
2019 : PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN 2019 401k financial data
Transfers to/from the plan	2019-12-31	$0
Total plan liabilities at end of year	2019-12-31	$0
Total plan liabilities at beginning of year	2019-12-31	$0
Total income from all sources	2019-12-31	$70,655
Expenses. Total of all expenses incurred	2019-12-31	$70,655
Benefits paid (including direct rollovers)	2019-12-31	$61,549
Total plan assets at end of year	2019-12-31	$0
Total plan assets at beginning of year	2019-12-31	$0
Total contributions received or receivable from participants	2019-12-31	$27,543
Expenses. Other expenses not covered elsewhere	2019-12-31	$0
Contributions received from other sources (not participants or employers)	2019-12-31	$0
Other income received	2019-12-31	$0
Noncash contributions received	2019-12-31	$0
Net income (gross income less expenses)	2019-12-31	$0
Net plan assets at end of year (total assets less liabilities)	2019-12-31	$0
Net plan assets at beginning of year (total assets less liabilities)	2019-12-31	$0
Total contributions received or receivable from employer(s)	2019-12-31	$43,112
Value of certain deemed distributions of participant loans	2019-12-31	$0
Value of corrective distributions	2019-12-31	$0
Expenses. Administrative service providers (salaries,fees and commissions)	2019-12-31	$9,106

Form 5500 Responses for PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND WELFARE PLAN

2019: PERRY'S LARKSPUR, LLC EMPLOYER HEALTH AND 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 funding arrangement – Trust	Yes
2019-01-01	Plan funding arrangement – General assets of the sponsor	Yes
2019-01-01	Plan benefit arrangement – Insurance	Yes
2019-01-01	Plan benefit arrangement - Trust	Yes
2019-01-01	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

UNITED HEALTHCARE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

Policy instance

Insurance contract or identification number	00
Number of Individuals Covered	8
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

PREMIER ACCESS INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 60237 )

Policy contract number

17833

Policy instance

Insurance contract or identification number	17833
Number of Individuals Covered	17
Insurance policy start date	2019-01-01
Insurance policy end date	2019-12-31
Total amount of commissions paid to insurance broker	USD $569
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Welfare Benefit Premiums Paid to Carrier	USD $6,620
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $569
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

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Company Name:	PERRY'S LARKSPUR, LLC
Employer identification number (EIN):	473336554
NAIC Classification:	722511
NAIC Description:	Full-Service Restaurants