| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| FORSITE BENEFIT PARTNERS3 | 2300 RIVERSIDE DRIVE SUITE 204 GREEN BAY, WI 54301 | BLUE CROSS BLUE SHIELD OF WISCONSIN | $48K | — | $48K | 1.51% |
| HNI RISK SERVICES3 Filed as: HNI RISK SERVICES LLC | PO BOX 51087 NEW BERLIN, WI 53151 | BLUE CROSS BLUE SHIELD OF WISCONSIN | $9K | — | $9K | 0.30% |
| TIMOTHY C MUELLER3 | 2300 RIVERSIDE DR GREEN BAY, WI 54301 | BLUE CROSS BLUE SHIELD OF MICHIGAN | $26K | — | $26K | 1.55% |
| JEFFREY A SCHULTZ3 Filed as: JEFFREY SHULTZ | 16805 W. CLEVLAND AVE NEW BERLIN, WI 53151 | BLUE CROSS BLUE SHIELD OF MICHIGAN | $12K | — | $12K | 0.73% |
| TIMOTHY C MUELLER3 | 2300 RIVERSIDE DR GREEN BAY, WI 54301 | BLUE CARE NETWORK OF MICHIGAN | $3K | — | $3K | 1.55% |
| JEFFREY A SCHULTZ3 Filed as: JEFFREY SHULTZ | 16805 W. CLEVLAND AVE NEW BERLIN, WI 53151 | BLUE CARE NETWORK OF MICHIGAN | $872 | — | $872 | 0.48% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| DELTA DENTAL OF WISCONSIN EIN 39-6094742 THIRD PARTY ADMINISTRATO | Contract Administrator Service code 13 | — | $19K |
| ACRISURE LLC INSURANCE AGENT OR BROKE | Insurance agents and brokers Service code 22 | PO BOX 51187 NEW BERLIN, WI 53151 | $3K |
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 | 467 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 1 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 16 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 484 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(3 contracts, 3 carriers) | BLUE CROSS BLUE SHIELD OF WISCONSIN | 476 | $5.0M |
| Vision | BLUE CROSS BLUE SHIELD OF WISCONSIN | 476 | $3.2M |
| Life insurance | BLUE CROSS BLUE SHIELD OF WISCONSIN | 476 | $3.2M |
| Short-term disability | BLUE CROSS BLUE SHIELD OF WISCONSIN | 476 | $3.2M |
| Long-term disability | BLUE CROSS BLUE SHIELD OF WISCONSIN | 476 | $3.2M |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 476 | — |
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."
Premium per covered life exceeds 2× the peer median for this NAICS + size cohort. Either richly-funded plan or struggling with a bad rate.