| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| VICTOR A CAMPANILE BROKERAGE INC3 | 2125 UTICA AVE BROOKLYN, NY 11234 | EMPIRE HEALTHCHOICE HMO, INC. | $25K | — | $25K | 2.31% |
| THOMAS FOLISE3 | 7 WEST 34TH STREET NEW YORK, NY 10001 | HIP HEALTH PLAN OF NY AN EMBLEM HEALTH COMPANY | $21K | — | $21K | 4.37% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| JOHN N MONGELLO EIN 11-1708617 HUSBAND- KATHY MONGELLO | Plan Administrator Service code 14 | 115 TOPAZ DRIVE FREEHOLD, NJ 07728 | $180K |
| JESSICA GAMBINO EIN 11-1708617 DAUGHTER- KATHY MONGELLO | Employee (plan) Service code 30 | 8 IROQUOIS DRIVE MANALAPAN, NJ 07726 | $85K |
| RESTAT, LLC EIN 38-3693753 NONE | Contract Administrator Service code 13 | 1516 PAYSPHERE CIRCLE CHICAGO, IL 60647 | $84K |
| FETINA SMALLHORNE EIN 11-1708617 NONE | Employee (plan) Service code 30 | 1139 PARK PLACE BROOKLYN, NY 11212 | $48K |
| GALINA FAYLORD EIN 11-1708617 NONE | Employee (plan) Service code 30 | 601 B SURF AVE APT 3N BROOKLYN, NY 11224 | $43K |
| ROSEMARIE MONGIELLO EIN 11-1708617 NONE | Employee (plan) Service code 30 | 225 KENSINGTON ROAD LYNBROOK, NY 11563 | $37K |
| VORMITTAG ASSOCIATES INC. EIN 11-2532460 NONE | Consulting (general) Service code 16 | 120 COMAC STREET RONKONKOMA, NY 11779 | $33K |
| S.A.KOENIG & ASSOCIATES CPAS, P.C. EIN 11-3141654 NONE | Accounting (including auditing) Service code 10 | 485 UNDERHILL BLVD SUITE 100 SYOSSET, NY 117913434 | $33K |
| TAMARA ARAKCHEYEVA EIN 11-1708617 NONE | Employee (plan) Service code 30 | 2942 WEST 5TH ST APT 7-K BROOKLYN, NY 11224 | $27K |
| MULTIPLAN, INC. EIN 13-3068979 NONE | Contract Administrator Service code 13 | PO BOX 29395 GPO NEW YORK, NY 100879395 | $21K |
| STARR, GERN, DAVISON, & RUBIN, PC EIN 22-3241223 NONE | Legal Service code 29 | 105 EISENHOWER PARKWAY SUITE 401 ROSELAND, NJ 070681640 | $14K |
| DDI CONSULTING SERVICES EIN 22-3369266 NONE | Consulting (general) Service code 16 | 221 SOMERVILLE ROAD BEDMINSTER, NJ 07921 | $10K |
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 | 635 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 0 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | EMPIRE HEALTHCHOICE HMO, INC. | 97 | $1.1M |
| Other | HIP HEALTH PLAN OF NY AN EMBLEM HEALTH COMPANY | 76 | $478K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 97 | — |
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."
Premium per covered life exceeds 2× the peer median for this NAICS + size cohort. Either richly-funded plan or struggling with a bad rate.
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.