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| Provider | Services | Address | Compensation |
|---|---|---|---|
| THE BENECON GROUP EIN 23-1315351 BROKER | Insurance agents and brokers Service code 22 | — | $1K |
| BSI CORPORATE BENEFITS, LLC EIN 51-0467698 BROKER | Insurance agents and brokers Service code 22 | — | $1K |
| HY HOLDINGS INC EIN 04-3705970 ADMIN. | Claims processing Service code 12 | — | $338 |
| INNOVU EIN 81-1938789 ADMIN. | Claims processing Service code 12 | — | $85 |
| CAPITAL BLUECROSS EIN 23-0455154 ADMIN. | Claims processing Service code 12 | — | -$369 |
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 | 38 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 0 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 38 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Dental | DELTA DENTAL OF PENNSYLVANIA | 31 | $2K |
| Vision | CAPITAL ADVANTAGE ASSURANCE COMPANY | 36 | $2K |
| Life insurance | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | 38 | $260 |
| Short-term disability | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | 38 | $1K |
| Stop-loss / reinsurancereinsurance | AVALON INSURANCE COMPANY | 20 | $5K |
| Other(2 contracts, 2 carriers) | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | 38 | $260 |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 38 | — |
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.