| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| DIVERSIFIED GROUP BROKERAGE CORP.3 Filed as: DIVERSIFIED ADMIN. CORP. | 369 NORTH MAIN STREET MARLBOROUGH, CT 064470299 | AIG BENEFIT SOLUTIONS | — | — | $0 | 0.00% |
| DIVERSIFIED GROUP BROKERAGE CORP.3 | P.O. BOX 299 MARLBOROUGH, CT 064470299 | UNITED OMAHA LIFE INSURANCE COMPANY | $3K | $268 | $3K | 27.23% |
| MICHAEL USIAK3 | 250 EAST MAIN STREET, 2ND FLOOR CLINTON, CT 06413 | AFLAC | $313 | $7 | $320 | 4.26% |
| PAMELA GRACEY3 Filed as: PAMELA A. GRACEY | 250 EAST MAIN STREET, 2ND FLOOR CLINTON, CT 06413 | AFLAC | $226 | $28 | $254 | 3.38% |
| MARY JANE SULLIVAN3 | P.O. BOX 306 SOUTH GLASTONBURY, CT 06073 | AFLAC | $150 | — | $150 | 2.00% |
| MJ INSURANCE3 Filed as: VARIOUS BROKERS | EACH RECEIVED LESS THAN 50 MIDDLETOWN, CT 06457 | AFLAC | $56 | $26 | $82 | 1.09% |
| DIVERSIFIED GROUP BROKERAGE CORP.3 | 369 NORTH MAIN STREET MARLBOROUGH, CT 064470299 | AFLAC | $81 | — | $81 | 1.08% |
| MICHAEL T REYES3 Filed as: MICHAEL T. REYES | 185 PLAINS ROAD, SUITE 200E MILFORD, CT 06461 | AFLAC | $66 | — | $66 | 0.88% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| DIVERSIFIED ADMINISTRATION CORP. EIN 06-0988547 THIRD PARTY ADMINISTRATOR | Claims processing Service code 12 | 369 NORTH MAIN STREET MARLBOROUGH, CT 06447 | $231K |
| CORPORATE MANAGED HEALTH SERVICES EIN 06-1421429 UTILIZATION REVIEW | Contract Administrator Service code 13 | 369 NORTH MAIN STREET MARLBOROUGH, CT 06447 | $48K |
| DAVID W. SULLIVAN AGENT | Custodial (securities) Service code 19 | 7 WATER STREET SOUTH GLASTONBURY, CT 06073 | $7K |
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 | 279 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 279 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | AIG BENEFIT SOLUTIONS | 174 | $29K |
| Life insurance | UNITED OMAHA LIFE INSURANCE COMPANY | 279 | $12K |
| Short-term disability | AFLAC | 7 | $8K |
| Other(2 contracts, 2 carriers) | BERKLEY ACCIDENT & HEALTH | 279 | $455K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 279 | — |
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.