| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| DAVID MIDDAUGH, CAPITAL FINANCIAL S3 | 1019 5TH AVE S FARGO, ND 58103 | GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY | $1K | $0 | $1K | — |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| GOLDLEAF PARTNERS EIN 45-0514557 CONTRACT ADMIN | Contract Administrator Service code 13 | P.O. BOX 806 BRAINERD, MN 56401 | $16K |
| CAPITAL FINANCIAL SERVICES, INC. | Other commissions Service code 55 | — | $14K |
| WIDMER ROEL PC EIN 45-0334950 AUDITOR | Accounting (including auditing) Service code 10 | 4334 18TH AVE S STE 101 FARGO, ND 58103 | $9K |
| GREAT-WEST LIFE & ANNUITY INSURANCE EIN 84-0467907 RECORDKEEPER | Recordkeeping fees Service code 64 | 8515 EAST ORCHARD ROAD GREENWOOD VILLAGE, CO 80111 | $2K |
| ADVISED ASSET GROUP INVESTMENT MANAGEMENT | Investment management Service code 28 | 8515 EAST ORCHARD ROAD GREENWOOD VILLAGE, CO 80111 | $959 |
| THE RETIREMENT ADVANTAGE, INC. EIN 39-1816008 CONTRACT ADMIN | Contract Administrator Service code 13 | 101 E GRAND AVENUE STE 16 PORT WASHINGTON, WI 53074 | $614 |
| CAPITAL FINANCIAL SERVICES INC EIN 45-0334950 BROKER / ADVISOR | Other commissions Service code 55 | 1 NORTH MAIN ST MINOT, ND 58703 | $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 | 105 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 77 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 68 | Vested but not currently using benefits. |
| Beneficiaries receiving benefits | 0 | Spouses or dependents with eligibility independent of the participant. |
| Total participants (= "Plan participants" tile) | 250 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Life insurance | GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY | 8 | $0 |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 8 | — |
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.