| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| ROXANNA DIETERLE3 | 300 OTTAWA GRAND RAPIDS, MI 49503 | PRIORITY HEALTH | $75K | — | $75K | 3.06% |
| GALLAGHER BENEFIT SERVICES, INC. Filed as: GALLAGHER BENEFIT SERVICES | PO BOX 3009 ARLINGTON HEIGHTS, IL 60006 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $11K | — | $11K | 5.32% |
| GALLAGHER BENEFIT SERVICES, INC. Filed as: GALLAGHER BENEFIT SERVICES | 2850 W GOLF RD 11TH FLOOR ROLLING MEADOWS, IL 60008 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $3K | — | $3K | 1.56% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES | PO BOX 3009 ARLINGTON HEIGHTS, IL 60006 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $9K | — | $9K | 15.00% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES | 2850 W GOLF RD 11TH FLOOR ROLLING MEADOWS, IL 60008 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $933 | — | $933 | 1.57% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES | PO BOX 3009 ARLINGTON HEIGHTS, IL 60006 | UNUM INSURANCE COMPANY | $5K | — | $5K | 20.00% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES | 2850 W GOLF RD 11TH FLOOR ROLLING MEADOWS, IL 60008 | UNUM INSURANCE COMPANY | $646 | — | $646 | 2.37% |
| GALLAGHER BENEFIT SERVICES, INC. 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 | PO BOX 3009 ARLINGTON HEIGHTS, IL 60006 | UNUM INSURANCE COMPANY | $5K | — | $5K | 20.00% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES | 2850 W GOLF RD 11TH FLOOR ROLLING MEADOWS, IL 60008 | UNUM INSURANCE COMPANY | $486 | — | $486 | 2.08% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES | PO BOX 3009 ARLINGTON HEIGHTS, IL 60006 | UNUM INSURANCE COMPANY | $4K | — | $4K | 19.99% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SERVICES | 2850 W GOLF RD 11TH FLOOR ROLLING MEADOWS, IL 60008 | UNUM INSURANCE COMPANY | $433 | — | $433 | 2.26% |
| PATRICIA SULLIVAN FORLETTA3 | 2600 S. TELEGRAPH STE 100 BLOOMFIELD HILLS, MI 48302 | BLUE CROSS BLUE SHIELD OF MICHIGAN | — | $4K | $4K | — |
| DOUGLAS L DERKS | 2600 S. TELEGRAPH STE 100 BLOOMFIELD HILLS, MI 48302 | BLUE CROSS BLUE SHIELD OF MICHIGAN | — | $2K | $2K | — |
| 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 | — | $984 | $984 | — |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| GALLAGHER BENEFIT SERVICES, INC. BROKER | Insurance agents and brokers; Non-monetary compensation; Other commissions; Other fees; Insurance brokerage commissions and fees Service code 22 | 2600 S. TELEGRAPH RD BLOOMFIELD HILLS, MI 48302 | $31K |
| BLUE CROSS & BLUE SHIELD OF MI EIN 38-2069753 TPA | Contract Administrator; Recordkeeping and information management (computing, tabulating, data processing, etc.); Consulting (general); Insurance services; Direct payment from the plan; Claims processing; Other fees; Float revenue 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 | 291 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 291 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | PRIORITY HEALTH | 489 | $2.5M |
| Dental | BLUE CROSS BLUE SHIELD OF MICHIGAN | 562 | $0 |
| Vision | NATIONAL VISION ADMINISTRATORS, LLC | 484 | $24K |
| Life insurance(2 contracts) | UNUM LIFE INSURANCE COMPANY OF AMERICA | 291 | $259K |
| Short-term disability | UNUM LIFE INSURANCE COMPANY OF AMERICA | 291 | $200K |
| Long-term disability | UNUM LIFE INSURANCE COMPANY OF AMERICA | 291 | $200K |
| Prescription drug | PRIORITY HEALTH | 489 | $2.5M |
| Other(5 contracts, 2 carriers) | UNUM LIFE INSURANCE COMPANY OF AMERICA | 291 | $329K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 562 | — |
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."
The primary carrier changed from prior filing. The plan is already willing to move; opportunity to re-pitch on the next cycle.
Top carrier holds >85% of premium. If that carrier hits a rate increase, the entire plan moves.