| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| GROUP BENEFIT ADMINISTRATORS OF CT3 | 109 SANFORD STREET HAMDEN, CT 06514 | ANTHEM LIFE INSURANCE COMPANY | $2K | — | $2K | 1.73% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| TRI STATE JOINT FUND EIN 06-0850110 AFFILIATED ORGANIZATION | Direct payment from the plan; Plan Administrator; Claims processing Service code 12 | — | $520K |
| 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 | — | $351K |
| CLAIMS PROCESSOR EIN 06-0944011 EMPLOYEE | Employee (plan); Direct payment from the plan Service code 30 | — | $145K |
| FEINBERG, DUMONT, BRENNAN & LIACOS NONE | Legal; Direct payment from the plan Service code 29 | 177 MILK STREET SUITE 300 BOSTON, MA 02109 | $60K |
| MED CARE MANAGEMENT INC EIN 88-0429522 NONE | Other services; Other fees Service code 49 | — | $54K |
| JOHNSON ASSET MANAGEMENT NONE | Investment management; Investment management fees paid directly by plan Service code 28 | 3777 WEST FORK ROAD CINCINNATI, OH 45247 | $39K |
| HMC HEALTHWORKS INC EIN 75-3189468 NONE | Other fees; Other services Service code 49 | — | $38K |
| FUND MANAGER EIN 06-0944011 EMPLOYEE | Direct payment from the plan; Employee (plan) Service code 30 | — | $28K |
| BOYD WATTERSON ASSET MGMT, LLC EIN 34-1922005 NONE | Investment management; Investment management fees paid directly by plan Service code 28 | 1801 E. 9TH STREET, SUITE 1400 CLEVELAND, OH 44114 | $20K |
| M&T BANK EIN 16-0538020 NONE | Direct payment from the plan; Other fees; Custodial (securities); Float revenue Service code 19 | ONE MT PLAZA BUFFALO, NY 14203 | $19K |
| INVESTMENT CONSULTING SERVICE EIN 32-0016703 NONE | Investment advisory (plan); Consulting fees; Direct payment from the plan Service code 27 | — | $18K |
| DAVIS VISION EIN 11-3051991 NONE | Other services; Other fees Service code 49 | — | $14K |
| PREFERRED NETWORK ACCESS EIN 36-4018433 NONE | Other fees; Insurance services Service code 23 | — | $7K |
| OPTUM RX EIN 33-0441200 NONE | Claims processing; Other services; Other fees Service code 12 | — | $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 | 0 | 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) | 0 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Life insurance | ANTHEM LIFE INSURANCE COMPANY | 1,987 | $130K |
| Other | ANTHEM LIFE INSURANCE COMPANY | 1,987 | $130K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 1,987 | — |
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.