| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| HUB INTERNATIONAL MIDWEST LIMITED3 | 55 E JACKSON BLVD CHICAGO, IL 60604 | EYEMED VISION CARE | $1K | — | $1K | 3.19% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| UNITED HEATHCARE SERVICES, INC EIN 41-1289245 CLAIMS PROCESSOR | Claims processing; Other services Service code 12 | — | $187K |
| LIBERTY LIFE ASSUR CO OF BOSTON EIN 04-6076039 CONTRACT ADMINISTRATOR | Contract Administrator Service code 13 | — | $26K |
| CIGNA HEALTH AND LIFE INSURANCE CO EIN 59-1031071 CLAIM ADMINISTRATION | Named fiduciary; Participant communication; Other services; Non-monetary compensation; Contract Administrator; Direct payment from the plan; Float revenue; Claims processing Service code 12 | — | $19K |
| LIBERTY MUTUAL ASSUR CO OF BOSTON EIN 04-6076039 CONTRACT ADMINISTRATOR | Contract Administrator Service code 13 | — | $10K |
| HUB INTERNATIONAL MIDWEST LTD EIN 35-0672425 BROKER | Other commissions Service code 55 | 55 E JACKSON BLVD CHICAGO, IL 606044466 | $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 | 1,450 | 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) | 1,450 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Vision | EYEMED VISION CARE | 2,465 | $46K |
| Life insurance | METROPOLITAN LIFE INSURANCE COMPANY | 1,450 | $255K |
| Long-term disability | LIBERTY LIFE ASSURANCE COMPANY OF BOSTON | 1,369 | $84K |
| Stop-loss / reinsurancereinsurance | UNITEDHEALTHCARE INSURANCE COMPANY | 2,482 | $300K |
| Other(2 contracts, 2 carriers) | METROPOLITAN LIFE INSURANCE COMPANY | 2,143 | $321K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 2,482 | — |
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.