| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| J.S. CLARK AGENCY, INC.3 Filed as: JS CLARK AGENCY INC | 25900 W 11 MILE RD SUITE 210 SOUTHFIELD, MI 48034 | BLUE CARE NETWORK OF MICHIGAN | $30K | — | $30K | 1.83% |
| J.S. CLARK AGENCY, INC.3 Filed as: JS CLARK AGENCY INC | 25900 W 11 MILE RD STE 210 SOUTHFIELD, MI 48034 | BLUE CROSS BLUE SHIELD OF MICHIGAN | $6K | — | $6K | 1.77% |
| J.S. CLARK AGENCY, INC.3 Filed as: JS CLARK AGENCY, INC | 25900 W 11 MILE RD SUITE 210 SOUTHFIELD, MI 48034 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $4K | $4K | $8K | 10.29% |
| J.S. CLARK AGENCY, INC.3 Filed as: JS CLARK AGENCY INC | 25900 W 11 MILE RD STE 210 SOUTHFIELD, MI 48034 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $5K | $2K | $6K | 20.23% |
| J.S. CLARK AGENCY, INC.3 Filed as: JS CLARK AGENCY INC | 25900 WEST ELEVEN MILE RD SOUTHFIELD, MI 48034 | FIDELITY SECURITY LIFE INSURANCE COMPANY / EYEMED VISION CARE | $2K | — | $2K | 9.98% |
| J.S. CLARK AGENCY, INC.3 Filed as: JS CLARK AGENCY INC | 25900 W 11 MILE RD STE 210 SOUTHFIELD, MI 48034 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $3K | $1K | $4K | 19.16% |
| J.S. CLARK AGENCY, INC.3 Filed as: JS CLARK AGENCY INC | 25900 W 11 MILE RD STE 210 SOUTHFIELD, MI 48034 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $2K | $523 | $2K | 12.76% |
| ROY LAMPHIER3 | 11 CAMBRIDGE BLVD PLEASANT RIDGE, MI 48069 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $2K | — | $2K | 10.00% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| BLUE CROSS BLUE SHIELD OF MICHIGAN EIN 38-2069753 TPA | Insurance services; Other fees; Recordkeeping and information management (computing, tabulating, data processing, etc.); Float revenue; Contract Administrator; Direct payment from the plan; Claims processing; Consulting (general) Service code 12 | 600 EAST LAFAYETTE BLVD DETROIT, MI 48226 | $8K |
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 | 179 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 179 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(2 contracts, 2 carriers) | BLUE CARE NETWORK OF MICHIGAN | 318 | $2.0M |
| Dental | BLUE CROSS BLUE SHIELD OF MICHIGAN | 37 | $336K |
| Vision | FIDELITY SECURITY LIFE INSURANCE COMPANY / EYEMED VISION CARE | 285 | $21K |
| Life insurance | UNITED OF OMAHA LIFE INSURANCE COMPANY | 180 | $19K |
| Short-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 180 | $74K |
| Long-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 60 | $19K |
| Prescription drug(2 contracts, 2 carriers) | BLUE CARE NETWORK OF MICHIGAN | 318 | $2.0M |
| Other | UNITED OF OMAHA LIFE INSURANCE COMPANY | 79 | $31K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 318 | — |
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."
No prospect flags tripped on this filing.