Filings through .
No insurance carriers on this filing. Self-funded welfare plans typically pay TPAs and PBMs through Schedule C, not Schedule A.
No brokers reported on this filing.
| Provider | Services | Address | Compensation |
|---|---|---|---|
| ANTHEM BLUE CROSS AND BLUE SHIELD | Claims processing; Contract Administrator; Recordkeeping and information management (computing, tabulating, data processing, etc.) Service code 12 | 3075 VANDERCAR WAY 262-212-7597 CINCINNATI, OH 45209 | $914K |
| PLAN ADMINISTRATOR EIN 42-0930021 | Plan Administrator Service code 14 | — | $112K |
| EMPLOYEE 1 EIN 42-0930021 | Employee (plan) Service code 30 | — | $101K |
| BRIDGEWAY BENEFIT TECHNOLOGIES, LLC EIN 52-1796473 | Recordkeeping and information management (computing, tabulating, data processing, etc.) Service code 15 | — | $97K |
| EMPLOYEE 2 EIN 42-0930021 | Employee (plan) Service code 30 | — | $94K |
| EMPLOYEE 5 EIN 42-0930021 | Employee (plan) Service code 30 | — | $70K |
| THE SEGAL COMPANY EIN 13-1975125 | Actuarial; Consulting (general) Service code 11 | — | $68K |
| INCOME RESEARCH & MANAGEMENT EIN 04-2955404 | Investment management; Investment management fees paid directly by plan Service code 28 | — | $68K |
| EMPLOYEE 4 EIN 42-0930021 | Employee (plan) Service code 30 | — | $50K |
| EMPLOYEE 3 EIN 42-0930021 | Employee (plan) Service code 30 | — | $48K |
| DEBOER & ASSOCIATES, PC EIN 47-0836395 | Accounting (including auditing) Service code 10 | — | $33K |
| FOX ROTHSCHILD, LLP EIN 23-1404723 | Legal Service code 29 | — | $31K |
| NINETY ONE INTERNATIONAL DYNAMIC EIN 41-2282919 | Investment management fees paid directly by plan; Investment management Service code 28 | — | $26K |
| ASSET CONSULTING GROUP EIN 43-1512694 | Investment advisory (plan) Service code 27 | — | $24K |
| IOWA STATE BANK EIN 42-0335294 | Custodial (securities) Service code 19 | — | $20K |
| NORTHERN TRUST INVESTMENTS EIN 45-6138596 | Investment management fees paid directly by plan; Investment management Service code 28 | — | $948 |
| SEGAL SELECT INSURANCE EIN 46-0619194 | Insurance brokerage commissions and fees Service code 53 | — | $0 |
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 | 1,516 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 303 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 1,819 | Active + retired/separated + beneficiaries. No dependents. |
No Schedule A insurance contracts on this filing — typical of fully self-funded plans, where the only headcount is the Form 5500 number above.
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."
Self-funded plan with no stop-loss carrier attached. Exposed to catastrophic claims. Stop-loss sales target.