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| Plan Name | BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN |
| Plan identification number | 901 |
| 401k Plan Type | Welfare Benefit |
| Plan Features/Benefits |
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| Company Name: | BLUE GOOSE CANTINA |
| Employer identification number (EIN): | 751975501 |
| NAIC Classification: | 722511 |
| NAIC Description: | Full-Service Restaurants |
| Plan id# | Filing Submission Date | Name of Administrator | Date Administrator Signed | Name of Company Sponsor | Date Sponsor Signed |
|---|---|---|---|---|---|
| 901 | 2019-01-01 | ||||
| 901 | 2018-01-01 | JOHN BONNO | JOHN BONNO | 2019-07-18 |
| Measure | Date | Value |
|---|---|---|
| 2019: BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN 2019 401k membership | ||
| Total participants, beginning-of-year | 2019-01-01 | 191 |
| Total number of active participants reported on line 7a of the Form 5500 | 2019-01-01 | 150 |
| Total of all active and inactive participants | 2019-01-01 | 150 |
| Total participants | 2019-01-01 | 150 |
| 2018: BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN 2018 401k membership | ||
| Total participants, beginning-of-year | 2018-01-01 | 229 |
| Total number of active participants reported on line 7a of the Form 5500 | 2018-01-01 | 191 |
| Total of all active and inactive participants | 2018-01-01 | 191 |
| Total participants | 2018-01-01 | 191 |
| Number of employers contributing to the scheme | 2018-01-01 | 1 |
| 2019: BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN 2019 form 5500 responses | ||
|---|---|---|
| 2019-01-01 | Type of plan entity | Single employer plan |
| 2019-01-01 | Submission has been amended | No |
| 2019-01-01 | This submission is the final filing | No |
| 2019-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2019-01-01 | Plan is a collectively bargained plan | No |
| 2019-01-01 | Plan funding arrangement – Insurance | Yes |
| 2019-01-01 | Plan benefit arrangement – Insurance | Yes |
| 2018: BLUE GOOSE CANTINA EMPLOEE GROUP HEALTH PLAN 2018 form 5500 responses | ||
| 2018-01-01 | Type of plan entity | Single employer plan |
| 2018-01-01 | Submission has been amended | No |
| 2018-01-01 | This submission is the final filing | No |
| 2018-01-01 | This return/report is a short plan year return/report (less than 12 months) | No |
| 2018-01-01 | Plan is a collectively bargained plan | No |
| 2018-01-01 | Plan funding arrangement – Insurance | Yes |
| 2018-01-01 | Plan benefit arrangement – Insurance | Yes |
| ASSURED BENEFITS ADMINISTRATORS (National Association of Insurance Commissioners NAIC id number: ) | |
| Policy contract number | 6168 |
| Policy instance | 1 |
| ALLIED NATIONAL COMPANIES (National Association of Insurance Commissioners NAIC id number: 60739 ) | |
| Policy contract number | |
| Policy instance | 1 |
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