| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| GROUP BENEFIT ADMINISTRATORS OF CT3 | 23 MAIDEN LANE NORTH HAVEN, CT 06473 | ANTHEM LIFE INSURANCE COMPANY | $2K | — | $2K | 1.73% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| TRI STATE JOINT FUND EIN 06-0850110 AFFILIATED ORG. | Plan Administrator; Direct payment from the plan; Claims processing Service code 12 | — | $469K |
| ANTHEM BLUE CROSS BLUE SHIELD EIN 06-1475928 NONE | Other services; Claims processing; Contract Administrator; Float revenue; Recordkeeping and information management (computing, tabulating, data processing, etc.) Service code 12 | — | $301K |
| UBS FINANCIAL SERVICES INC EIN 13-2638166 NONE | Investment management fees paid directly by plan; Investment advisory (plan); Investment management fees paid indirectly by plan; Other fees Service code 27 | — | $226K |
| PREFERRED ACCESS NETWORK EIN 36-4018433 NONE | Other fees; Other services Service code 49 | 1510 2. 75TH STREET SUITE 250 DARIEN, IL 60561 | $69K |
| KATHYLYNN PATTERSON EIN 06-0942913 EMPLOYEE | Direct payment from the plan; Employee (plan) Service code 30 | — | $57K |
| MICHELLE PISANO EIN 06-0942913 EMPLOYEE | Employee (plan); Direct payment from the plan Service code 30 | — | $49K |
| MED CARE MANAGEMENT INC EIN 88-0429522 NONE | Other fees; Other services Service code 49 | — | $47K |
| PATRICIA ANDREWS EIN 06-0942913 EMPLOYEE | Direct payment from the plan; Employee (plan) Service code 30 | — | $44K |
| KYLE MACRI EIN 06-0942913 EMPLOYEE | Direct payment from the plan; Employee (plan) Service code 30 | — | $43K |
| HEALTH MANAGEMENT CONCEPTS, INC EIN 75-3189468 NONE | Other services; Other fees Service code 49 | 181 COMMODORE DRIVE JUPITER, FL 33477 | $38K |
| TEAMSTERS RX EIN 02-6015031 NONE | Consulting (general); Other fees; Contract Administrator Service code 13 | 51 GOFFSTOWN ROAD MANCHESTER, NH 03102 | $21K |
| EXPRESS SCRIPTS, INC EIN 22-3461740 NONE | Other fees; Other services Service code 49 | — | $19K |
| S M ESPOSITO & COMPANY INC EIN 06-1298465 NONE | Accounting (including auditing); Direct payment from the plan Service code 10 | — | $17K |
| TIM CASEY EIN 06-0942913 EMPLOYER TRUSTEE | Direct payment from the plan; Trustee (individual) Service code 20 | — | $12K |
| THOMAS BAYUSIK EIN 06-0942913 UNION TRUSTEE | Trustee (individual); Direct payment from the plan Service code 20 | — | $11K |
| DAVIS VISION EIN 11-3051991 NONE | Other services; Other fees Service code 49 | — | $8K |
| STRATOSE INC EIN 26-1790538 NONE | Other fees; Other services Service code 49 | — | $7K |
| MPL LLC EIN 06-1537302 NONE | Insurance brokerage commissions and fees; Insurance agents and brokers; Other commissions Service code 22 | — | $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 | 912 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 52 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 1,121 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 2,085 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Life insurance | ANTHEM LIFE INSURANCE COMPANY | 914 | $116K |
| Other | ANTHEM LIFE INSURANCE COMPANY | 914 | $116K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 914 | — |
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."
Top carrier holds >85% of premium. If that carrier hits a rate increase, the entire plan moves.
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.