| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| PAUL KAHLER3 | 25900 W 11 MILE RD, SUITE 210 SOUTHFIELD, MI 480348203 | BLUE CROSS BLUE SHIELD OF MICHIGAN | $14K | $23K | $37K | 1.18% |
| J.S. CLARK AGENCY, INC.3 Filed as: J.S. CLARK AGENCY | 25900 W 11 MILE RD, SUITE 210 SOUTHFIELD, MI 480348203 | BLUE CROSS BLUE SHIELD OF MICHIGAN | $4K | $9K | $13K | 0.43% |
| J.S. CLARK AGENCY, INC.3 | 25900 W. 11 MILE ROAD, SUITE 210 SOUTHFIELD, MI 48034 | DELTA DENTAL OF MICHIGAN | $12K | — | $12K | 4.75% |
| J.S. CLARK AGENCY, INC.3 | 25900 W 11 MILE RD, SUITE 210 SOUTHFIELD, MI 48034 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $10K | $5K | $15K | 14.84% |
| J.S. CLARK AGENCY, INC.3 Filed as: JS CLARK AGENCY INC | 25900 W. ELEVEN MILE, SUITE 210 SOUTHFIELD, MI 480348203 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $12K | — | $12K | 20.00% |
| J.S. CLARK AGENCY, INC.3 | 25900 W 11 MILE RD, SUITE 210 SOUTHFIELD, MI 48034 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $5K | $3K | $8K | 14.87% |
| J.S. CLARK AGENCY, INC.3 | 25900 W 11 MILE RD, SUITE 210 SOUTHFIELD, MI 48034 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $3K | $3K | $5K | 9.84% |
| J.S. CLARK AGENCY, INC.3 | 25900 W 11 MILE RD, SUITE 210 SOUTHFIELD, MI 48034 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $3K | $1K | $4K | 14.86% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| BLUE CROSS BLUE SHIELD OF MICHIGAN EIN 38-2069753 TPA | Contract Administrator; Recordkeeping and information management (computing, tabulating, data processing, etc.); Consulting (general); Insurance services; Float revenue; Claims processing; Other fees; Direct payment from the plan Service code 12 | — | $155K |
| J.S. CLARK AGENCY, INC. EIN 38-2725572 AGENT | Insurance agents and brokers; Insurance brokerage commissions and fees; Other fees; Non-monetary compensation; Other commissions Service code 22 | 25900 W 11 MILE, STE 210 SOUTHFIELD, MI 480348203 | $61K |
| PAUL KAHLER AGENT | Other commissions; Insurance agents and brokers; Insurance brokerage commissions and fees; Non-monetary compensation; Other fees Service code 22 | 25900 W 11 MILE, STE 210 SOUTHFIELD, MI 480348203 | $37K |
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 | 207 | 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) | 207 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | BLUE CROSS BLUE SHIELD OF MICHIGAN | 189 | $3.1M |
| Dental | DELTA DENTAL OF MICHIGAN | 454 | $250K |
| Vision | BLUE CROSS BLUE SHIELD OF MICHIGAN | 189 | $3.1M |
| Life insurance(2 contracts) | UNITED OF OMAHA LIFE INSURANCE COMPANY | 207 | $84K |
| Short-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 206 | $103K |
| Long-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 207 | $53K |
| Prescription drug | BLUE CROSS BLUE SHIELD OF MICHIGAN | 189 | $3.1M |
| Other(2 contracts, 2 carriers) | UNUM LIFE INSURANCE COMPANY OF AMERICA | 207 | $114K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 454 | — |
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.
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.