| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| JOHNSON INSURANCE SERVICES LLC3 | 525 JUNCTION ROAD SUITE 2000 MADISON, WI 53717 | UNUM LIFE INSURANCE COMPANY OF AMERICA | — | $603 | $603 | 1.25% |
| JOHNSON INSURANCE SERVICES LLC3 Filed as: JOHNSON INSURANCE SERVICES INC | 525 JUNCTION ROAD SUITE 2000 MADISON, WI 53717 | UNUM LIFE INSURANCE OF AMERICA | $2K | — | $2K | 15.00% |
| JOHNSON INSURANCE SERVICES LLC3 Filed as: JOHNSON INSURANCE SERVICES INC | 525 JUNCTION RD MADISON, WA 53717 | UNUM LIFE INSURANCE OF AMERICA | — | $147 | $147 | 1.25% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| PRAIRIE STATES ENTERPRISES, INC. EIN 36-3730559 THIRD PARTY ADMINISTRATO | Claims processing; Contract Administrator Service code 12 | 402 N MICHIGAN AVE SUITE 2902 CHICAGO, IL 60611 | $49K |
| EMPLOYER HEALTH CARE ALLIANCE EIN 39-1675538 ADMINISTRATOR | Plan Administrator Service code 14 | 5510 NOBEL DRIVE SUITE 200 FITCHBURG, WI 53711 | $12K |
| DELTA DENTAL OF WISCONSIN EIN 39-6094742 THIRD PARTY ADMINISTRATO | Contract Administrator Service code 13 | 2801 HOOVER RD PO BOX 828 STEVENS POINT, WI 54481 | $4K |
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 | 143 | 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) | 143 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Life insurance(2 contracts, 2 carriers) | UNUM LIFE INSURANCE COMPANY OF AMERICA | 143 | $60K |
| Long-term disability | UNUM LIFE INSURANCE COMPANY OF AMERICA | 143 | $48K |
| Other(2 contracts, 2 carriers) | UNUM LIFE INSURANCE COMPANY OF AMERICA | 143 | $60K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 143 | — |
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.