| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| BSI CORPORATE BENEFITS LLC3 | 79 W. MARKET ST SUITE 400 BETHLEHEM, PA 180185749 | AMERITAS | $2K | $0 | $2K | 10.00% |
| BSI CORPORATE BENEFITS LLC3 | 28411 NORTHWESTERN HWY SUITE 1150 SOUTHFIELD, MI 48034 | NATIONAL VISION ADMINISTRATORS NGL | $113 | $0 | $113 | 5.00% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| GEISINGER HEALTH PLAN EIN 23-2815174 ADMIN | Claims processing Service code 12 | — | $25K |
| BSI CORPORATE BENEFITS BROKER | Insurance agents and brokers Service code 22 | 79 WEST MARKET ST, SUITE 400 BETHLEHEM, PA 18018 | $17K |
| THE BENECON GROUP EIN 23-1315351 BROKER | Insurance agents and brokers Service code 22 | — | $12K |
| 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 | 1 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 43 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Dental | AMERITAS | 74 | $20K |
| Vision | NATIONAL VISION ADMINISTRATORS NGL | 49 | $2K |
| Life insurance | UNITED OF OMAHA LIFE INSURANCE COMPANY | 0 | $0 |
| Short-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 0 | $0 |
| Long-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 0 | $0 |
| Stop-loss / reinsurancereinsurance | EVEREST REINSURANCE COMPANY | 43 | $118K |
| Other | UNITED OF OMAHA LIFE INSURANCE COMPANY | 0 | $0 |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 74 | — |
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.