| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| RICHARD L DONNER3 Filed as: RICHARD L. DONNER | 333 INDUSTRIAL DRIVE ADRIAN, MI 492218780 | BLUE CROSS BLUE SHIELD OF MICHIGAN | $16K | — | $16K | 1.79% |
| KAPNICK & COMPANY, INC.3 Filed as: KAPNICK INSURANCE & CO., INC. | 1201 BRIARWOOD CIRCLE ANN ARBOR, MI 481081690 | BLUE CROSS BLUE SHIELD OF MICHIGAN | — | $2K | $2K | 0.23% |
| STEPHEN GRACIN3 Filed as: STEPHEN J PECK | 26100 AMERICAN DRIVE SUITE 300 SOUTHFIELD, MI 48034 | BLUE CROSS BLUE SHIELD OF MICHIGAN | — | $33 | $33 | 0.00% |
| TYRONE JORDAN3 | P.O. BOX 1801 ADRIAN, MI 49221 | BLUE CROSS BLUE SHIELD OF MICHIGAN | — | $33 | $33 | 0.00% |
| KATHERINE C WOOD3 Filed as: KATHERINE WOOD | 1201 BRIARWOOD CIRCLE ANN ARBOR, MI 48108 | BLUE CROSS BLUE SHIELD OF MICHIGAN | — | $26 | $26 | 0.00% |
| KAPNICK & COMPANY, INC.3 | 333 INDUSTRIAL DRIVE ADRIAN, MI 49221 | THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA | $5K | $1K | $7K | 15.51% |
| KAPNICK & COMPANY, INC.3 | P.O. BOX 1801 ADRIAN, MI 49221 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $626 | $61 | $687 | 1.74% |
| KAPNICK & COMPANY, INC.3 | P.O. BOX 1801 ADRIAN, MI 49221 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $3K | $248 | $3K | 21.75% |
| KAPNICK & COMPANY, INC.3 Filed as: KAPNICK INSURANCE GROUP | 26100 AMERICAN DRIVE SUITE 300 SOUTHFIELD, MI 48034 | ZURICH AMERICAN INSURANCE COMPANY | $927 | — | $927 | 18.00% |
No Schedule C service providers reported on this filing.
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 | 166 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 3 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Beneficiaries receiving benefits | 0 | Spouses or dependents with eligibility independent of the participant. |
| Total participants (= "Plan participants" tile) | 169 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | BLUE CROSS BLUE SHIELD OF MICHIGAN | 300 | $895K |
| Life insurance(2 contracts, 2 carriers) | THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA | 141 | $83K |
| Long-term disability(2 contracts, 2 carriers) | THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA | 146 | $58K |
| Prescription drug | BLUE CROSS BLUE SHIELD OF MICHIGAN | 300 | $895K |
| Other(2 contracts, 2 carriers) | UNUM LIFE INSURANCE COMPANY OF AMERICA | 141 | $45K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 300 | — |
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."
Top carrier holds >85% of premium. If that carrier hits a rate increase, the entire plan moves.
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.