| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| USI INSURANCE SERVICES LLC3 Filed as: USI MIDWEST LLC | PO BOX 62889 VIRGINIA BEACH, VA 23466 | UNUM LIFE INSURANCE COMPANY OF AMERICA | — | $5K | $5K | 1.58% |
| USI INSURANCE SERVICES LLC3 Filed as: USI MIDWEST LLC | PO BOX 62889 VIRGINIA BEACH, VA 23466 | UNUM LIFE INSURANCE COMPANY OF AMERICA | — | $3K | $3K | 1.47% |
| USI INSURANCE SERVICES LLC3 Filed as: USI INSURANCE SERVICES, LLC | ATTN MIDWEST DIRECT BILL PO VIRGINIA BEACH, VA 23466 | EYEMED VISION CARE ON BEHALF OF THE COMBINED INSURANCE CO. OF AMERICA | $13K | — | $13K | 10.05% |
| AON CONSULTING INC3 Filed as: AON HEWITT - INDIANAPOLIS | 450 EAST 96TH STREET SUITE 275 INDIANAPOLIS, IN 46240 | EYEMED VISION CARE | $6K | — | $6K | 10.85% |
| USI INSURANCE SERVICES LLC3 Filed as: USI INSURANCE SERVICES, LLC | ATTN MIDWEST DIRECT BILL PO VIRGINIA BEACH, VA 23466 | EYEMED VISION CARE ON BEHALF OF THE COMBINED INSURANCE CO. OF AMERICA | $1K | — | $1K | 9.73% |
| USI INSURANCE SERVICES LLC3 Filed as: USI INSURANCE SERVICES, LLC | ATTN MIDWEST DIRECT BILL PO VIGINIA BEACH, VA 23466 | EYEMED VISION CARE ON BEHALF OF THE COMBINED INSURANCE CO. OF AMERICA | $227 | — | $227 | 9.18% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| EXPRESS SCRIPTS, INC. EIN 43-1420563 NONE | Contract Administrator; Claims processing Service code 12 | — | $1.8M |
| UNITED HEALTHCARE SERVICES, INC. EIN 41-1289245 NONE | Other services; Claims processing Service code 12 | — | $787K |
| CUSTOM DESIGN BENEFIT EIN 82-0563218 NONE | Contract Administrator; Claims processing Service code 12 | — | $68K |
| DELTA DENTAL OF OHIO EIN 31-0685339 NONE | Contract Administrator; Claims processing Service code 12 | — | $48K |
| DIAMOND CONSULTING EIN 54-1515550 NONE | Claims processing; Contract Administrator Service code 12 | — | $19K |
| USI MIDWEST INC EIN 31-0507943 NONE | Other commissions Service code 55 | — | $0 |
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 | 1,850 | 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) | 1,850 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Vision(5 contracts, 2 carriers) | EYEMED VISION CARE ON BEHALF OF THE COMBINED INSURANCE CO. OF AMERICA | 1,290 | $282K |
| Life insurance(2 contracts) | UNUM LIFE INSURANCE COMPANY OF AMERICA | 1,850 | $557K |
| Long-term disability | UNUM LIFE INSURANCE COMPANY OF AMERICA | 1,850 | $333K |
| Stop-loss / reinsurancereinsurance | HCC LIFE INSURANCE COMPANY | 1,078 | $781K |
| Other | UNUM LIFE INSURANCE COMPANY OF AMERICA | 1,850 | $333K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 1,850 | — |
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.