| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| AMWINS5 | 50 WHITECAP DRIVE N KINGSTOWN, RI 02852 | HARTFORD LIFE & ACCIDENT INSURANCE CO. MEDICARE SUPPLEMENT | $15K | — | $15K | 6.66% |
| ASSUREDPARTNERS5 Filed as: HACKETT, VALINE & MACDONALD INC | 140 KENNEDY DRIVE SO BURLINGTON, VT 05403 | HARTFORD LIFE & ACCIDENT INSURANCE CO. MEDICARE SUPPLEMENT | $7K | — | $7K | 3.34% |
| SENIOR MARKET SALES INC5 Filed as: SENIOR MARKET SALES | 8420 WEST DODGE RD SUITE 510 OMAHA, NE 68114 | HARTFORD LIFE & ACCIDENT INSURANCE CO. MEDICARE SUPPLEMENT | $2K | — | $2K | 1.11% |
| COMBINED SERVICES LLC3 | PO BOX 1320 CONCORD, NH 03302 | NORTHEAST DELTA DENTAL | $2K | — | $2K | 1.01% |
| NFP INSURANCE SERVICES INC3 Filed as: NFP CORPORATE SERVICES NY LL | 340 MADISON AVE NEW YORK, NY 10173 | THE HARTFORD GROUP BENEFITS DIVISION | $7K | — | $7K | 10.00% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| CIGNA HEALTH AND LIFE INSURANCE CO. EIN 59-1031071 PROVIDES CLAIMS ADMIN | Other services; Named fiduciary; Float revenue; Claims processing; Participant communication; Contract Administrator; Direct payment from the plan; Non-monetary compensation Service code 12 | PO BOX 644546 PITTSBURGH, PA 15264 | $5.2M |
| ANNE HOULE EIN 03-0210827 SALARY FOR KEY EMPLOYEE | Plan Administrator; Insurance services; Employee (plan sponsor) Service code 14 | PO BOX 345 BARRE, VT 05641 | $65K |
| ANN REGAN EIN 03-0210827 ADMINISTRATIVE WAGES | Recordkeeping and information management (computing, tabulating, data processing, etc.); Employee (plan sponsor) Service code 15 | PO BOX 345 BARRE, VT 05641 | $15K |
| GRANITE GROUP INSURANCE TRUST EIN 03-0210827 CONTRACT ADMINSTRATION | Contract Administrator; Claims processing Service code 12 | PO BOX 345 BARRE, VT 05641 | $0 |
| HACKETTE, VALINE, & MAC DONALD EIN 03-0235322 AGENT BROKER | Insurance brokerage commissions and fees Service code 53 | 620 HINESBURG RD SO BURLINGTON, VT 05407 | $0 |
Benefits declared on the Form 5500 main form (✓ = also has a Schedule A insurance contract; otherwise the benefit is funded out of plan assets or via a Schedule C TPA).
The plan reports several different headcounts depending on which form you read. Each one measures a different slice of the population.
| Active participants | 358 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 174 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Beneficiaries receiving benefits | 0 | Spouses or dependents with eligibility independent of the participant. |
| Total participants (= "Plan participants" tile) | 532 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(2 contracts, 2 carriers) | CIGNA HEALTH AND LIFE INSURANCE COMPANY | 354 | $660K |
| Dental | NORTHEAST DELTA DENTAL | 582 | $156K |
| Vision | VISION SERVICE PLAN | 280 | $31K |
| Life insurance | THE HARTFORD GROUP BENEFITS DIVISION | 324 | $74K |
| Stop-loss / reinsurancereinsurance | CIGNA HEALTH AND LIFE INSURANCE COMPANY | 354 | $435K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 582 | — |
Why the numbers differ. Form 5500 line 6 counts employees + retirees + beneficiaries; no dependents. Schedule A persons-covered counts everyone enrolled, including spouses and children, so it usually exceeds line 6 by 30-60% on a working-age workforce. The medical row is normally the broadest single line because it has the highest take-up; dental/vision/life often dip below it. Stop-loss / reinsurance contracts sometimes report the carrier's full underwriting pool rather than this filer's headcount; the row is shown for transparency but shouldn't be read as "people in this plan."
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.