| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| AXA ASSISTANCE, USA5 | 122 SOUTH MICHIGAN AVENUE SUITE 100 CHICAGO, IL 606036115 | PRUDENTIAL | $32 | $0 | $32 | 0.05% |
| RSC INSURANCE BROKERAGE INC3 Filed as: RSC INSURANCE BROKERAGE, INC. | 420 LEXINGTON AVE. RM2700 NEW YORK, NY 101702799 | VISION SERVICE PLAN | $309 | $0 | $309 | 6.78% |
| DEWITT STERN GROUP PLANNING SERVICE3 Filed as: DEWITT STERN GROUP | 420 LEXINGTON AVE. RM 2700 NEW YORK, NY 101702799 | VISION SERVICE PLAN | $147 | $0 | $147 | 3.23% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| PRUDENTIAL INSURANCE CO OF AMERICA EIN 22-1211670 THIRD PARTY ADMINISTRATOR | Claims processing Service code 12 | — | $1K |
| COMPSYCH EIN 35-3739783 THIRD PARTY ADMINISTRATOR | Claims processing Service code 12 | — | $982 |
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 | 78 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 44 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 11 | Vested but not currently using benefits. |
| Beneficiaries receiving benefits | 0 | Spouses or dependents with eligibility independent of the participant. |
| Total participants (= "Plan participants" tile) | 133 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | HORIZON HEALTHCARE SERVICES, INC. | 90 | $860K |
| Dental | HORIZON HEALTHCARE SERVICES, INC. | 95 | $50K |
| Vision | VISION SERVICE PLAN | 54 | $5K |
| Life insurance | PRUDENTIAL | 95 | $65K |
| Long-term disability | PRUDENTIAL | 95 | $65K |
| Prescription drug | HORIZON HEALTHCARE SERVICES, INC. | 90 | $860K |
| Other | PRUDENTIAL | 95 | $65K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 95 | — |
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.