| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| CIBC OF ILLINOIS INC | 187 S SCHUYLER AVE STE 500 KANKAKEE, IL 60901 | BLUE CROSS BLUE SHIELD OF ILLINOIS | $30K | — | $30K | — |
| VISTA NATIONAL INSURANCE GROUP INC Filed as: VISTA NATIONAL INSURANCE GROUP | 1415 W 22ND STE 1000 OAK BROOK, IL 60523 | BLUE CROSS BLUE SHIELD OF ILLINOIS | -$4K | — | -$4K | — |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| BLUE CROSS BLUE SHIELD OF ILLINOIS EIN 36-1236610 INSURANCE CARRIER | Claims processing Service code 12 | 300 EAST RANDOLPH ST CHICAGO, IL 60601 | $140K |
| CIBC OF ILLINOIS INC EIN 36-3862778 AGENT | Insurance agents and brokers Service code 22 | 187 S SCHUYLER AVE 500 KANKAKEE, IL 60901 | $30K |
| VISTA NATIONAL INSURANCE GROUP EIN 36-4095485 AGENT | Insurance agents and brokers Service code 22 | 1415 W 22ND ST STE 1000 OAK BROOK, IL 60523 | -$4K |
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 | 384 | 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) | 384 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | BLUE CROSS BLUE SHIELD OF ILLINOIS | 384 | $0 |
| Prescription drug | BLUE CROSS BLUE SHIELD OF ILLINOIS | 384 | $0 |
| Stop-loss / reinsurancereinsurance | BLUE CROSS BLUE SHIELD OF ILLINOIS | 384 | $0 |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 384 | — |
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.