| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| CLINTON POLLEY GROUP3 Filed as: CLINTON POLLEY GROUP, INC. | 12150 TRIBUTARY POINT DR STE 200 GOLD RIVER, CA 95670 | KAISER FOUNDATION HEALTH PLAN INC. | $40K | — | $40K | 5.34% |
| AMWINS3 Filed as: LISI, INC (GA) | 1600 W HILLSDALE BLVD 201 SAN MATEO, CA 94402 | KAISER FOUNDATION HEALTH PLAN INC. | $16K | — | $16K | 2.14% |
| CLINTON POLLEY GROUP3 Filed as: CLINTON POLLEY GROUP, INC. | 12150 TRIBUTARY POINT DRIVE STE 200 GOLD RIVER, CA 95670 | CYPRESS DENTAL ADMINISTRATORS | $24K | — | $24K | 4.41% |
| CLINTON POLLEY GROUP3 Filed as: CLINTON POLLY INSURANCE BROKERS | 12150 TRIBUTARY PT DR STE 200 GOLD RIVER, CA 95670 | VISION SERVICE PLAN | $2K | — | $2K | 2.17% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| BENEFIT & RISK MANAGEMENT SERVICES NONE | Consulting (general) Service code 16 | 80 IRON POINT CIRCLE SUITE 200 FOLSOM, CA 95630 | $418K |
| ANTHEM BLUE CROSS LIFE AND HEALTH I EIN 95-4331852 NONE | Float revenue; Other services; Claims processing; Recordkeeping and information management (computing, tabulating, data processing, etc.); Contract Administrator Service code 12 | 3075 VANDEREAR WAY CINCINNATI, OH 45209 | $240K |
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 | 1,122 | 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) | 1,122 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(3 contracts, 3 carriers) | VOYA | 1,122 | $1.7M |
| Dental | CYPRESS DENTAL ADMINISTRATORS | 1,070 | $544K |
| Vision | VISION SERVICE PLAN | 711 | $96K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 1,122 | — |
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."
Total premium grew more than 20% over prior year. Renewal pain — prime candidate for re-shopping the carriers.