401k Plan data: VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN plan

VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN 401k Plan overview

Plan Name	VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN
Plan identification number	501

VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN Benefits

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

VALENCIA 23 RESTAURANT INVESTORS, LLC has sponsored the creation of one or more 401k plans.

Company Name: VALENCIA 23 RESTAURANT INVESTORS, LLC

Employer identification number (EIN): 731728662

NAIC Classification: 722511
NAIC Description: Full-Service Restaurants

Additional information about VALENCIA 23 RESTAURANT INVESTORS, LLC

Jurisdiction of Incorporation: California Department of State

Incorporation Date:

Company Identification Number: 200436410172

More information about VALENCIA 23 RESTAURANT INVESTORS, LLC

Form 5500 Filing Information

Submission information for form 5500 for 401k plan VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2016-02-01 ADRIANO PAGANINI
501 2015-02-01 ADRIANO PAGANINI

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2016-02-01	ADRIANO PAGANINI
501	2015-02-01	ADRIANO PAGANINI

Plan Statistics for VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN

401k plan membership statisitcs for VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN

Measure Date Value
2016: VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year 2016-02-01 100
Total number of active participants reported on line 7a of the Form 5500 2016-02-01 0
Number of retired or separated participants receiving benefits 2016-02-01 0
Number of other retired or separated participants entitled to future benefits 2016-02-01 0
Total of all active and inactive participants 2016-02-01 0
2015: VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year 2015-02-01 100
Total number of active participants reported on line 7a of the Form 5500 2015-02-01 95
Number of retired or separated participants receiving benefits 2015-02-01 0
Number of other retired or separated participants entitled to future benefits 2015-02-01 0
Total of all active and inactive participants 2015-02-01 95

Measure	Date	Value
2016: VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN 2016 401k membership
Total participants, beginning-of-year	2016-02-01	100
Total number of active participants reported on line 7a of the Form 5500	2016-02-01	0
Number of retired or separated participants receiving benefits	2016-02-01	0
Number of other retired or separated participants entitled to future benefits	2016-02-01	0
Total of all active and inactive participants	2016-02-01	0
2015: VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN 2015 401k membership
Total participants, beginning-of-year	2015-02-01	100
Total number of active participants reported on line 7a of the Form 5500	2015-02-01	95
Number of retired or separated participants receiving benefits	2015-02-01	0
Number of other retired or separated participants entitled to future benefits	2015-02-01	0
Total of all active and inactive participants	2015-02-01	95

Form 5500 Responses for VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN

2016: VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN 2016 form 5500 responses
2016-02-01	Type of plan entity	Single employer plan
2016-02-01	Submission has been amended	No
2016-02-01	This submission is the final filing	Yes
2016-02-01	This return/report is a short plan year return/report (less than 12 months)	Yes
2016-02-01	Plan is a collectively bargained plan	No
2016-02-01	Plan funding arrangement – Insurance	Yes
2016-02-01	Plan benefit arrangement – Insurance	Yes
2015: VALENCIA 23 RESTAURANT INVESTORS, LLC BENEFITS PLAN 2015 form 5500 responses
2015-02-01	Type of plan entity	Single employer plan
2015-02-01	First time form 5500 has been submitted	Yes
2015-02-01	Submission has been amended	No
2015-02-01	This submission is the final filing	No
2015-02-01	This return/report is a short plan year return/report (less than 12 months)	No
2015-02-01	Plan is a collectively bargained plan	No
2015-02-01	Plan funding arrangement – Insurance	Yes
2015-02-01	Plan benefit arrangement – Insurance	Yes

Insurance Providers Used on plan

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

Policy contract number

15624

Policy instance

Insurance contract or identification number	15624
Number of Individuals Covered	8
Insurance policy start date	2014-03-01
Insurance policy end date	2015-02-28
Total amount of commissions paid to insurance broker	USD $344
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	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 $2,907
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $212
Insurance broker organization code?	3
Insurance broker name	WARNER PACIFIC INSURANCE

KAISER FOUNDATION HEALTH PLAN OF HAWAII (National Association of Insurance Commissioners NAIC id number: 0000 )

Policy contract number

660890

Policy instance

Insurance contract or identification number	660890
Number of Individuals Covered	101
Insurance policy start date	2015-02-01
Insurance policy end date	2016-01-31
Total amount of commissions paid to insurance broker	USD $10,643
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	No
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 $193,281
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $10,643
Insurance broker organization code?	3
Insurance broker name	DIABLO VALLEY BENEFITS, LLC

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 00000 )

Policy contract number

30011245

Policy instance

Insurance contract or identification number	30011245
Number of Individuals Covered	18
Insurance policy start date	2014-12-01
Insurance policy end date	2015-05-31
Total amount of commissions paid to insurance broker	USD $171
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 $1,706
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $114
Insurance broker organization code?	3
Insurance broker name	DIABLO VALLEY BENEFITS, LLC

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Company Name:	VALENCIA 23 RESTAURANT INVESTORS, LLC
Employer identification number (EIN):	731728662
NAIC Classification:	722511
NAIC Description:	Full-Service Restaurants

Jurisdiction of Incorporation:	California Department of State
Incorporation Date:
Company Identification Number:	200436410172