401k Plan data: ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN plan

ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN 401k Plan overview

Plan Name	ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN
Plan identification number	502

ATLANTA BREAD COMPANY INTERNATIONAL INC 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) Long-term disability cover Death benefits (include travel accident but not life insurance) 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

ATLANTA BREAD COMPANY INTERNATIONAL, INC. has sponsored the creation of one or more 401k plans.

Company Name: ATLANTA BREAD COMPANY INTERNATIONAL, INC.

Employer identification number (EIN): 582273557

NAIC Classification: 311800
NAIC Description: Bakeries and Tortilla Manufacturing

Form 5500 Filing Information

Submission information for form 5500 for 401k plan ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
502 2016-03-01
502 2015-03-01 ANTHONY DAVIS
502 2011-03-01 ADAM HOLZHAUER

Plan Statistics for ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN

401k plan membership statisitcs for ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN

Measure Date Value
2016: ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year 2016-03-01 196
Total number of active participants reported on line 7a of the Form 5500 2016-03-01 196
Number of retired or separated participants receiving benefits 2016-03-01 1
Number of other retired or separated participants entitled to future benefits 2016-03-01 0
Total of all active and inactive participants 2016-03-01 197
2015: ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year 2015-03-01 112
Total number of active participants reported on line 7a of the Form 5500 2015-03-01 173
Number of retired or separated participants receiving benefits 2015-03-01 0
Number of other retired or separated participants entitled to future benefits 2015-03-01 0
Total of all active and inactive participants 2015-03-01 173
2011: ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year 2011-03-01 114
Total number of active participants reported on line 7a of the Form 5500 2011-03-01 132
Number of retired or separated participants receiving benefits 2011-03-01 0
Number of other retired or separated participants entitled to future benefits 2011-03-01 0
Total of all active and inactive participants 2011-03-01 132
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits 2011-03-01 0

Measure	Date	Value
2016: ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN 2016 401k membership
Total participants, beginning-of-year	2016-03-01	196
Total number of active participants reported on line 7a of the Form 5500	2016-03-01	196
Number of retired or separated participants receiving benefits	2016-03-01	1
Number of other retired or separated participants entitled to future benefits	2016-03-01	0
Total of all active and inactive participants	2016-03-01	197
2015: ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN 2015 401k membership
Total participants, beginning-of-year	2015-03-01	112
Total number of active participants reported on line 7a of the Form 5500	2015-03-01	173
Number of retired or separated participants receiving benefits	2015-03-01	0
Number of other retired or separated participants entitled to future benefits	2015-03-01	0
Total of all active and inactive participants	2015-03-01	173
2011: ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN 2011 401k membership
Total participants, beginning-of-year	2011-03-01	114
Total number of active participants reported on line 7a of the Form 5500	2011-03-01	132
Number of retired or separated participants receiving benefits	2011-03-01	0
Number of other retired or separated participants entitled to future benefits	2011-03-01	0
Total of all active and inactive participants	2011-03-01	132
Number of deceased participants whose beneficiaries are receiving or are entitled to receive benefits	2011-03-01	0

Form 5500 Responses for ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN

2016: ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN 2016 form 5500 responses
2016-03-01	Type of plan entity	Single employer plan
2016-03-01	Submission has been amended	No
2016-03-01	This submission is the final filing	No
2016-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2016-03-01	Plan is a collectively bargained plan	No
2016-03-01	Plan funding arrangement – Insurance	Yes
2016-03-01	Plan funding arrangement – General assets of the sponsor	Yes
2016-03-01	Plan benefit arrangement – Insurance	Yes
2016-03-01	Plan benefit arrangement – General assets of the sponsor	Yes
2015: ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN 2015 form 5500 responses
2015-03-01	Type of plan entity	Single employer plan
2015-03-01	Submission has been amended	No
2015-03-01	This submission is the final filing	No
2015-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-03-01	Plan is a collectively bargained plan	No
2015-03-01	Plan funding arrangement – Insurance	Yes
2015-03-01	Plan benefit arrangement – Insurance	Yes
2011: ATLANTA BREAD COMPANY INTERNATIONAL INC WELFARE BENEFIT PLAN 2011 form 5500 responses
2011-03-01	Type of plan entity	Single employer plan
2011-03-01	First time form 5500 has been submitted	Yes
2011-03-01	Submission has been amended	No
2011-03-01	This submission is the final filing	No
2011-03-01	This return/report is a short plan year return/report (less than 12 months)	No
2011-03-01	Plan is a collectively bargained plan	No
2011-03-01	Plan funding arrangement – Insurance	Yes
2011-03-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

BLUE CROSS BLUE SHIELD OF GEORGIA INC. (G0386) (National Association of Insurance Commissioners NAIC id number: 96962 )

Policy contract number

GA7037

Policy instance

Insurance contract or identification number	GA7037
Number of Individuals Covered	112
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $37,041
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
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
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $747,946
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $37,041
Insurance broker organization code?	3
Insurance broker name	PAYCHEX INSURANCE AGENCY INC

METROPOLITAN LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 65978 )

Policy contract number

TM05926674

Policy instance

Insurance contract or identification number	TM05926674
Number of Individuals Covered	173
Insurance policy start date	2015-03-01
Insurance policy end date	2016-02-29
Total amount of commissions paid to insurance broker	USD $2,951
Total amount of fees paid to insurance company	USD $92
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $39,673
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $2,942
Amount paid for insurance broker fees	89
Additional information about fees paid to insurance broker	FEES PAID
Insurance broker organization code?	3
Insurance broker name	JOHNSON AND BRYAN INC

BLUE CROSS BLUE SHIELD HEALTHCARE PLAN OF GEORGIA INC (National Association of Insurance Commissioners NAIC id number: )

Policy contract number

1011165000

Policy instance

Insurance contract or identification number	1011165000
Number of Individuals Covered	74
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $19,336
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	No
Life Insurance Welfare Benefit	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $391,293
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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

Policy contract number

9692435

Policy instance

Insurance contract or identification number	9692435
Number of Individuals Covered	132
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $203
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
Health Insurance Welfare Benefit	No
Dental Insurance Welfare Benefit	No
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
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $3,804
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

PRUDENTIAL ANNUITIES SERVICE (National Association of Insurance Commissioners NAIC id number: 68241 )

Policy contract number

09723

Policy instance

Insurance contract or identification number	09723
Number of Individuals Covered	114
Insurance policy start date	2011-03-01
Insurance policy end date	2012-02-29
Total amount of commissions paid to insurance broker	USD $4,208
Total amount of fees paid to insurance company	USD $31
Are there contracts with allocated funds for individual policies?	No
Are there contracts with allocated funds for group deferred annuity?	No
Are there contracts with allocated funds for types other than group deferred annuity or individual?	No
Contract purchased, in whole or in part, to distribute benefits from a terminating plan	No
Contracts With Unallocated Funds Deposit Administration	0
Are there contracts with unallocated funds for contracts of type immediate participation guarantee?	No
Are there contracts with unallocated funds for contracts of type guaranteed investment?	No
Are there contracts with unallocated funds for contract types other than deposit administration, immediate participation guarantee or guaranteed investment?	No
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	Yes
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	VOLUNTARY LIFE ACCIDENTAL DEATH AND DISMEMBERMENT
Were dividends or retroactive rate refunds paid in cash?	No
Were dividends or retroactive rate refunds paid as a credit?	No
Welfare Benefit Premiums Paid to Carrier	USD $56,105
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No

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Company Name:	ATLANTA BREAD COMPANY INTERNATIONAL, INC.
Employer identification number (EIN):	582273557
NAIC Classification:	311800
NAIC Description:	Bakeries and Tortilla Manufacturing

Plan id#	Filing Submission Date	Name of Administrator
502	2016-03-01
502	2015-03-01	ANTHONY DAVIS
502	2011-03-01	ADAM HOLZHAUER