| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| PCI INSURANCE AGENCY3 Filed as: PCI INSURANCE, INC | 417 WALNUT STREET HARRISBURG, PA 17101 | UNITED CONCORDIA INSURANCE COMPANY | $0 | $137 | $137 | 0.75% |
| PCI INSURANCE AGENCY3 Filed as: PCI INSURANCE, INC | 417 WALNUT STREET HARRISBURG, PA 17101 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $1K | $0 | $1K | 12.99% |
| ASSUREDPARTNERS3 Filed as: GUNN-MOWERY LLC | 650 NORTH 12TH ST LEMOYNE, PA 17043 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $99 | $8 | $107 | 1.20% |
| ASSUREDPARTNERS3 Filed as: GUNN-MOWERY, LLC | 650 NORTH 12TH STREET LEMOYNE, PA 17043 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $97 | $0 | $97 | 2.29% |
| PCI INSURANCE AGENCY3 Filed as: PCI INSURANCE, INC | 417 WALNUT STREET HARRISBURG, PA 17101 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $215 | $0 | $215 | 8.25% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| CAPITAL BLUE CROSS EIN 45-5492167 ADMIN | Claims processing Service code 12 | — | $18K |
| PCI INSURANCE EIN 25-1784573 BROKER | Insurance agents and brokers Service code 22 | 417 WALNUT STREET HARRISBURG, PA 17101 | $12K |
| THE BENECON GROUP EIN 23-1315351 BROKER | Insurance agents and brokers Service code 22 | — | $8K |
| CONNECTCARE 3 EIN 26-1768616 PATIENT ADVOCATE | Other services Service code 49 | — | $2K |
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 | 42 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 2 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 44 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Dental | UNITED CONCORDIA INSURANCE COMPANY | 58 | $18K |
| Vision | CAPITAL ADVANTAGE ASSURANCE COMPANY | 42 | $3K |
| Life insurance | UNUM LIFE INSURANCE COMPANY OF AMERICA | 21 | $9K |
| Short-term disability | UNUM LIFE INSURANCE COMPANY OF AMERICA | 25 | $3K |
| Long-term disability | UNUM LIFE INSURANCE COMPANY OF AMERICA | 21 | $9K |
| Stop-loss / reinsurancereinsurance | EVEREST REINSURANCE COMPANY | 42 | $164K |
| Other(2 contracts) | UNUM LIFE INSURANCE COMPANY OF AMERICA | 21 | $13K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 58 | — |
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.