| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| BSI CORPORATE BENEFITS LLC3 | 79 W MARKET ST STE 400 BETHLEHEM, PA 18018 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $920 | $0 | $920 | 10.00% |
| BSI CORPORATE BENEFITS LLC3 Filed as: BSI CORPORATE BENEFITS, LLC | 29100 NORTHWESTERN HWY SUITE 310 SOUTHFIELD, MI 48034 | CAPITAL ADVANTAGE ASSURANCE COMPANY | $759 | $0 | $759 | 9.36% |
| BSI CORPORATE BENEFITS LLC3 | 79 W MARKET ST STE 400 BETHLEHEM, PA 18018 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $691 | $0 | $691 | 15.00% |
| BSI CORPORATE BENEFITS LLC3 | 79 W MARKET ST STE 400 BETHLEHEM, PA 18018 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $412 | $0 | $412 | 14.99% |
| BSI CORPORATE BENEFITS LLC3 | 79 W MARKET ST STE 400 BETHLEHEM, PA 18018 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $233 | $0 | $233 | 9.99% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| CAPITAL BLUE CROSS EIN 23-0455154 CARRIER | Claims processing Service code 12 | — | $20K |
| BSI CORPORATE BENEFITS, LLC BROKER | Insurance agents and brokers Service code 22 | 79 WEST MARKET STREET SUITE 400 BETHLEHEM, PA 18018 | $7K |
| THE BENECON GROUP EIN 23-1315351 BROKER | Insurance agents and brokers Service code 22 | — | $3K |
| HY HOLDINGS INC. DBA HEALTHIEST YOU EIN 30-0947669 BROKER | Insurance agents and brokers Service code 22 | — | $1K |
| CONNECTCARE3, LLC EIN 26-1768616 PATIENT ADVOCATE | Other services Service code 49 | — | $697 |
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 | 30 | 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) | 30 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Dental | CAPITAL ADVANTAGE ASSURANCE COMPANY | 45 | $8K |
| Vision | CAPITAL ADVANTAGE ASSURANCE COMPANY | 45 | $8K |
| Life insurance | UNITED OF OMAHA LIFE INSURANCE COMPANY | 43 | $2K |
| Short-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 43 | $9K |
| Stop-loss / reinsurancereinsurance | EVEREST REINSURANCE COMPANY | 31 | $46K |
| Other(3 contracts) | UNITED OF OMAHA LIFE INSURANCE COMPANY | 43 | $10K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 45 | — |
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.