401k Plan data: BERTUCCI'S RESTAURANT HEALTH AND WELFARE PLAN plan

BERTUCCI'S RESTAURANT HEALTH AND WELFARE PLAN 401k Plan overview

Plan Name	BERTUCCI'S RESTAURANT HEALTH AND WELFARE PLAN
Plan identification number	501

BERTUCCI'S RESTAURANT HEALTH AND WELFARE 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) Death benefits (include travel accident but not life insurance)

401k Sponsoring company profile

BERTUCCI'S RESTAURANT LLC has sponsored the creation of one or more 401k plans.

Company Name: BERTUCCI'S RESTAURANT LLC

Employer identification number (EIN): 830799571

NAIC Classification: 722511
NAIC Description: Full-Service Restaurants

Form 5500 Filing Information

Submission information for form 5500 for 401k plan BERTUCCI'S RESTAURANT HEALTH AND WELFARE PLAN

Plan id# Filing Submission Date Name of Administrator Date Administrator Signed Name of Company Sponsor Date Sponsor Signed
501 2018-06-21 CHRISTINE MOSCARITOLO 2019-10-11
501 2018-06-21 CHRISTINE MOSCARITOLO 2020-09-24

Plan id#	Filing Submission Date	Name of Administrator	Date Administrator Signed	Name of Company Sponsor	Date Sponsor Signed
501	2018-06-21	CHRISTINE MOSCARITOLO	2019-10-11
501	2018-06-21	CHRISTINE MOSCARITOLO	2020-09-24

Plan Statistics for BERTUCCI'S RESTAURANT HEALTH AND WELFARE PLAN

401k plan membership statisitcs for BERTUCCI'S RESTAURANT HEALTH AND WELFARE PLAN

Measure Date Value
2018: BERTUCCI'S RESTAURANT HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year 2018-06-21 100
Total number of active participants reported on line 7a of the Form 5500 2018-06-21 146
Number of retired or separated participants receiving benefits 2018-06-21 0
Number of other retired or separated participants entitled to future benefits 2018-06-21 0
Total of all active and inactive participants 2018-06-21 146
Number of employers contributing to the scheme 2018-06-21 0

Measure	Date	Value
2018: BERTUCCI'S RESTAURANT HEALTH AND WELFARE PLAN 2018 401k membership
Total participants, beginning-of-year	2018-06-21	100
Total number of active participants reported on line 7a of the Form 5500	2018-06-21	146
Number of retired or separated participants receiving benefits	2018-06-21	0
Number of other retired or separated participants entitled to future benefits	2018-06-21	0
Total of all active and inactive participants	2018-06-21	146
Number of employers contributing to the scheme	2018-06-21	0

Form 5500 Responses for BERTUCCI'S RESTAURANT HEALTH AND WELFARE PLAN

2018: BERTUCCI'S RESTAURANT HEALTH AND WELFARE PLAN 2018 form 5500 responses
2018-06-21	Type of plan entity	Single employer plan
2018-06-21	First time form 5500 has been submitted	Yes
2018-06-21	Submission has been amended	Yes
2018-06-21	This submission is the final filing	Yes
2018-06-21	This return/report is a short plan year return/report (less than 12 months)	Yes
2018-06-21	Plan is a collectively bargained plan	No
2018-06-21	Plan funding arrangement – Insurance	Yes
2018-06-21	Plan funding arrangement – General assets of the sponsor	Yes
2018-06-21	Plan benefit arrangement – Insurance	Yes
2018-06-21	Plan benefit arrangement – General assets of the sponsor	Yes

Insurance Providers Used on plan

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 )

Policy contract number

30085120

Policy instance

Insurance contract or identification number	30085120
Number of Individuals Covered	146
Insurance policy start date	2018-06-21
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Vision Insurance Welfare Benefit	Yes
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

NATIONWIDE LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 66869 )

Policy contract number

FV1167

Policy instance

Insurance contract or identification number	FV1167
Number of Individuals Covered	67
Insurance policy start date	2018-06-22
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,154
Total amount of fees paid to insurance company	USD $0
Health Insurance Welfare Benefit	Yes
Dental Insurance Welfare Benefit	Yes
Vision Insurance Welfare Benefit	Yes
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $27,005
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Are there contracts with allocated funds for individual policies?	0
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
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
Commission paid to Insurance Broker	USD $1,993
Insurance broker organization code?	3

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

01-016077-00

Policy instance

Insurance contract or identification number	01-016077-00
Number of Individuals Covered	146
Insurance policy start date	2018-06-21
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,085
Total amount of fees paid to insurance company	USD $988
Life Insurance Welfare Benefit	Yes
Temporary Disability Insurance Welfare Benefit	Yes
Other welfare benefits provided	ACCIDENTAL DEATH AND DISMEMBERMENT
Welfare Benefit Premiums Paid to Carrier	USD $82,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes
Commission paid to Insurance Broker	USD $3,385
Amount paid for insurance broker fees	988
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

E0490235

Policy instance

Insurance contract or identification number	E0490235
Number of Individuals Covered	121
Insurance policy start date	2018-06-21
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $156
Total amount of fees paid to insurance company	USD $0
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
Welfare Benefit Premiums Paid to Carrier	USD $9,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $93
Amount paid for insurance broker fees	0
Insurance broker organization code?	3

SYMETRA LIFE INSURANCE COMPANY (National Association of Insurance Commissioners NAIC id number: 68608 )

Policy contract number

0101607700

Policy instance

Insurance contract or identification number	0101607700
Number of Individuals Covered	146
Insurance policy start date	2018-06-21
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $4,085
Total amount of fees paid to insurance company	USD $988
Are there contracts with allocated funds for individual policies?	0
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	No
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 $82,328
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $3,385
Amount paid for insurance broker fees	988
Additional information about fees paid to insurance broker	ADDITIONAL COMPENSATION
Insurance broker organization code?	3

UNUM LIFE INSURANCE COMPANY OF AMERICA (National Association of Insurance Commissioners NAIC id number: 62235 )

Policy contract number

E0490235

Policy instance

Insurance contract or identification number	E0490235
Number of Individuals Covered	121
Insurance policy start date	2018-06-21
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $155
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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	No
Temporary Disability Insurance Welfare Benefit	No
Long Term Disability Insurance Welfare Benefit	No
Unemployment Insurance Welfare Benefit	No
Other welfare benefits provided	ACCIDENT, CRITICAL ILLNESS
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 $9,980
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	No
Commission paid to Insurance Broker	USD $93
Insurance broker organization code?	3

VISION SERVICE PLAN (National Association of Insurance Commissioners NAIC id number: 47317 )

Policy contract number

30085120

Policy instance

Insurance contract or identification number	30085120
Number of Individuals Covered	146
Insurance policy start date	2018-06-21
Insurance policy end date	2018-12-31
Total amount of commissions paid to insurance broker	USD $0
Total amount of fees paid to insurance company	USD $0
Are there contracts with allocated funds for individual policies?	0
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
Did the insurance company fail to provide any information necessary to complete Schedule A of form 5500?	Yes

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Company Name:	BERTUCCI'S RESTAURANT LLC
Employer identification number (EIN):	830799571
NAIC Classification:	722511
NAIC Description:	Full-Service Restaurants