| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| AXA ASSISTANCE, USA5 | 122 SOUTH MICHIGAN AVENUE SUITE 1100 CHICAGO, IL 606036115 | PRUDENTIAL INSURANCE COMPANY OF AMERICA | — | $2K | $2K | 0.06% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| UNITED HEALTHCARE SERVICES, INC. EIN 41-1289245 NONE | Contract Administrator; Claims processing; Other services Service code 12 | — | $4.0M |
| VITALITY EIN 45-0644624 NONE | Other services Service code 49 | — | $874K |
| QUEST DIAGNOSTICS EIN 38-2084239 NONE | Other services Service code 49 | — | $335K |
| PREMISE HEALTH EMPLOYER SOLUTIONS EIN 23-3057155 NONE | Other services Service code 49 | — | $242K |
| UNITED BEHAVIORAL HEALTH DBA OPTUM EIN 94-2649097 NONE | Contract Administrator; Claims processing Service code 12 | — | $178K |
| OPTUMHEALTH BANK EIN 47-0858534 NONE | Trustee (bank, trust company, or similar financial institution) Service code 21 | — | $172K |
| LIFE INSURANCE CO OF NORTH AMERICA EIN 23-1503749 NONE | Contract Administrator Service code 13 | — | $111K |
| ERNST & YOUNG EIN 34-6565596 NONE | Consulting (general) Service code 16 | — | $80K |
| WEIGHT WATCHERS EIN 52-1656141 NONE | Other services Service code 49 | — | $79K |
| WILLIS TOWERS WATSON EIN 23-1159360 NONE | Consulting (general) Service code 16 | — | $54K |
| WALGREENS EIN 36-1924025 NONE | Other services Service code 49 | — | $50K |
| AMERICAN HEART ASSOCIATION EIN 13-5613797 NONE | Direct payment from the plan Service code 50 | — | $21K |
| CLARK,SCHAEFER,HACKETT & CO EIN 31-0800053 NONE | Accounting (including auditing) Service code 10 | — | $18K |
| MERCER EIN 13-2834414 NONE | Consulting (general) Service code 16 | — | $18K |
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 | 6,377 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 428 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 6,805 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(2 contracts, 2 carriers) | HAWAII MEDICAL SERVICES ASSOCIATION | 177 | $556K |
| Dental | DELTA DENTAL OF OHIO | 12,741 | $4.8M |
| Vision | COMBINED INSURANCE COMPANY OF AMERICA | 10,668 | $745K |
| Life insurance | PRUDENTIAL INSURANCE COMPANY OF AMERICA | 6,540 | $3.8M |
| Long-term disability | LIFE INSURANCE COMPANY OF NORTH AMERICA | 6,229 | $1.3M |
| Prescription drug | UNITED HEALTHCARE INSURANCE COMPANY | 177 | $254K |
| Other(4 contracts, 4 carriers) | PRUDENTIAL INSURANCE COMPANY OF AMERICA | 6,540 | $6.6M |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 12,741 | — |
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."
Broker comp is under 1% of premium on a >$1M plan. Plan may be flying solo or paying a flat fee — consultant sales target.