| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| LAKESHORE BENEFIT GROUP INSURANCE3 | 529 MAIN ST, STE 2B NEW HARTFORD, CT 06057 | GERBER LIFE INSURANCE COMPANY | $9K | — | $9K | 2.00% |
| LAKESHORE BENEFIT GROUP INSURANCE3 | PO BOX 670 NEW HARTFORD, CT 060570670 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $3K | — | $3K | 10.00% |
| LAKESHORE BENEFIT GROUP INSURANCE3 | 529 MAIN ST, STE 2B NEW HARTFORD, CT 06057 | AETNA LIFE INSURANCE CO | $1K | — | $1K | 5.25% |
| LAKESHORE BENEFIT GROUP INSURANCE3 | PO BOX 670 NEW HARTFORD, CT 060570670 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $2K | — | $2K | 10.00% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| HORIZON HEALTHCARE SERVICES EIN 22-0999690 NONE | Contract Administrator; Direct payment from the plan Service code 13 | — | $472K |
| I. E. SHAFFER & CO. EIN 22-1750854 NONE | Direct payment from the plan; Contract Administrator Service code 13 | — | $192K |
| SUSANIN WIDMAN & BRENNAN, PC EIN 23-2265950 NONE | Legal; Direct payment from the plan Service code 29 | — | $113K |
| LOCAL 3170 NONE | Direct payment from the plan; Recordkeeping and information management (computing, tabulating, data processing, etc.) Service code 15 | 1201 NEW ROAD LINWOOD, NJ 08221 | $46K |
| NOVAK FRANCELLA EIN 61-1436956 NONE | Accounting (including auditing); Direct payment from the plan Service code 10 | — | $27K |
| CLEARY JOSEM & TRIGIANI, LLP EIN 23-2657967 NONE | Legal; Direct payment from the plan Service code 29 | — | $26K |
| JOHN M. FOWLER EIN 22-3789539 TRUSTEE | Trustee (individual); Direct payment from the plan Service code 20 | — | $22K |
| ADELMAN & GETTLEMAN, LTD. NONE | Legal; Direct payment from the plan Service code 29 | 53 W JACKSON BLVD. 1050 CHICAGO, IL 60604 | $5K |
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 | 1,298 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 6 | Continuation coverage (COBRA, retiree health). |
| Total participants (= "Plan participants" tile) | 1,304 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Dental(3 contracts, 2 carriers) | INTERNATIONAL HEALTHCARE SERVICES INC | 382 | $271K |
| Life insurance | AETNA LIFE INSURANCE CO | 412 | $27K |
| Short-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 162 | $30K |
| Long-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 162 | $21K |
| Stop-loss / reinsurancereinsurance | GERBER LIFE INSURANCE COMPANY | 1,306 | $431K |
| Other | AETNA LIFE INSURANCE CO | 412 | $27K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 1,306 | — |
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."
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.