| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| EVETTE SUSAN KENDZIERSKI3 | 22596 CLEARWATER DR MACOMB, MI 48044 | COLONIAL LIFE & ACCIDENT INSURANCE COMPANY | $66 | $0 | $66 | — |
| KENNETH JAMES BOWERY3 | 18810 WOODS DR W CLINTON TOWNSHIP, MI 48036 | COLONIAL LIFE & ACCIDENT INSURANCE COMPANY | $4 | $0 | $4 | — |
| THOMAS G. GORE1 | 36243 EGAN CLINTON TOWNSHIP, MI 48035 | NIPPON LIFE INSURANCE COMPANY OF AMERICA | $13K | $0 | $13K | — |
| CHELTEN BENEFITS GROUP2 Filed as: CHELTEN BENEFITS GROUP AGENCY, INC. | 4768 PARKVIEW DRIVE CLARKSTON, MI 48346 | NIPPON LIFE INSURANCE COMPANY OF AMERICA | $6K | $0 | $6K | — |
| NATIONAL GENERAL NSM SALES CORP3 Filed as: NATIONAL GENERAL NSM SALES CORP. | 100 NW COMPTON DRIVE SUITE 200 HILLSBORO, OR 97006 | NIPPON LIFE INSURANCE COMPANY OF AMERICA | $4K | $0 | $4K | — |
| THOMAS G. GORE1 | 36423 EGAN CLINTON TOWNSHIP, MI 48035 | PRIORITY HEALTH (HMO) | $23K | $0 | $23K | — |
| THOMAS G. GORE2 | 36423 EGAN CLINTON TOWNSHIP, MI 48035 | PRIORITY HEALTH (PPO) | $14K | $0 | $14K | — |
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 | 113 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 113 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(2 contracts, 2 carriers) | PRIORITY HEALTH (HMO) | 162 | $0 |
| Dental | NIPPON LIFE INSURANCE COMPANY OF AMERICA | 131 | $0 |
| Vision | NIPPON LIFE INSURANCE COMPANY OF AMERICA | 131 | $0 |
| Life insurance | NIPPON LIFE INSURANCE COMPANY OF AMERICA | 131 | $0 |
| Short-term disability | NIPPON LIFE INSURANCE COMPANY OF AMERICA | 131 | $0 |
| Long-term disability | NIPPON LIFE INSURANCE COMPANY OF AMERICA | 131 | $0 |
| Other | COLONIAL LIFE & ACCIDENT INSURANCE COMPANY | 3 | $0 |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 162 | — |
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.