| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| ROXANNA DIETERLE3 | 2600 S TELEGRAPH STE 100 BLOOMFIELD HILLS, MI 483028302 | BLUE CARE NETWORK OF MICHIGAN | $42K | — | $42K | 2.01% |
| DOUGLAS L DERKS3 | 2600 S TELEGRAPH STE 100 BLOOMFIELD HILLS, MI 483028302 | BLUE CARE NETWORK OF MICHIGAN | $20K | — | $20K | 0.96% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES | 2600 S TELEGRAPH STE 100 BLOOMFIELD HILLS, MI 483028302 | BLUE CARE NETWORK OF MICHIGAN | — | $2K | $2K | 0.11% |
| GALLAGHER BENEFIT SERVICES, INC.3 | PO BOX 3009 ARLINGTON HEIGHTS, IL 60006 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $11K | — | $11K | 6.58% |
| GALLAGHER BENEFIT SERVICES, INC.3 | 2850 W GOLF RD 11TH FLOOR ROLLING MEADOWS, IL 60008 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $3K | — | $3K | 1.97% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES INC. | PO BOX 3009 ARLINGTON HEIGHTS, IL 60006 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $8K | — | $8K | 17.33% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES INC. | 2850 W GOLF RD 11TH FLOOR ROLLING MEADOWS, IL 60008 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $929 | — | $929 | 1.98% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES | 2850 GOLF ROAD ROLLING MEADOWS, IL 60008 | NATIONAL VISION ADMINISTRATORS, LLC | $2K | — | $2K | 10.00% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES INC | PO BOX 3009 ARLINGTON HEIGHTS, IL 60006 | UNUM INSURANCE COMPANY | $3K | — | $3K | 20.00% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES INC | 2850 W GOLF RD 11TH FLOOR ROLLING MEADOWS, IL 60008 | UNUM INSURANCE COMPANY | $396 | — | $396 | 2.50% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES INC | PO BOX 3009 ARLINGTON HEIGHTS, IL 60006 | UNUM INSURANCE COMPANY | $3K | — | $3K | 20.00% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES INC | 2850 W GOLF RD 11TH FLOOR ROLLING MEADOWS, IL 60008 | UNUM INSURANCE COMPANY | $292 | — | $292 | 1.92% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES INC | PO BOX 3009 ARLINGTON HEIGHTS, IL 60006 | UNUM INSURANCE COMPANY | $3K | — | $3K | 19.97% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES INC | 2850 W GOLF RD 11TH FLOOR ROLLING MEADOWS, IL 60008 | UNUM INSURANCE COMPANY | $252 | — | $252 | 1.98% |
| DOUGLAS L DERKS3 | 2600 S TELEGRAPH STE 100 BLOOMFIELD HILLS, MI 48302 | BLUE CROSS BLUE SHIELD OF MICHIGAN | — | $6K | $6K | — |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES | 2600 S TELEGRAPH STE 100 BLOOMFIELD HILLS, MI 48302 | BLUE CROSS BLUE SHIELD OF MICHIGAN | — | $1K | $1K | — |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| ROXANNA DIETERLE INSURANCE AGENT | Other fees; Non-monetary compensation; Insurance brokerage commissions and fees; Insurance agents and brokers; Other commissions Service code 22 | 2600 S TELEGRAPH RD BLOOMFIELD HILLS, MI 48302 | $42K |
| GALLAGHER BENEFIT SERVICES INC BROKER | Insurance brokerage commissions and fees; Non-monetary compensation; Other fees; Other commissions; Insurance agents and brokers Service code 22 | 2600 S TELEGRAPH RD BLOOMFIELD HILLS, MI 48302 | $32K |
| DOUGLAS DERKS INSURANCE AGENT | Insurance agents and brokers; Non-monetary compensation; Insurance brokerage commissions and fees; Other fees; Other commissions Service code 22 | 2600 S TELEGRAPH RD BLOOMFIELD HILLS, MI 48302 | $26K |
| BLUE CROSS AND BLUE SHIELD OF MI EIN 38-2069753 TPA | Float revenue; Insurance services; Consulting (general); Claims processing; Other fees; Contract Administrator; Direct payment from the plan; Recordkeeping and information management (computing, tabulating, data processing, etc.) Service code 12 | — | $15K |
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 | 294 | 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) | 294 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | BLUE CARE NETWORK OF MICHIGAN | 505 | $2.1M |
| Dental | BLUE CROSS BLUE SHIELD OF MICHIGAN | 555 | $0 |
| Vision | NATIONAL VISION ADMINISTRATORS, LLC | 501 | $24K |
| Life insurance(2 contracts) | UNUM LIFE INSURANCE COMPANY OF AMERICA | 279 | $212K |
| Short-term disability | UNUM LIFE INSURANCE COMPANY OF AMERICA | 279 | $165K |
| Long-term disability | UNUM LIFE INSURANCE COMPANY OF AMERICA | 279 | $165K |
| Prescription drug | BLUE CARE NETWORK OF MICHIGAN | 505 | $2.1M |
| Other(5 contracts, 2 carriers) | UNUM LIFE INSURANCE COMPANY OF AMERICA | 279 | $256K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 555 | — |
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."
Primary broker changed. Recently changed advisors; vulnerable to a second-look pitch or hostile takeover.
Top carrier holds >85% of premium. If that carrier hits a rate increase, the entire plan moves.