| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| MOUNTAIN WEST INSURANCE3 | 100 E VICTORY WAY CRAIG, CO 81625 | PRUDENTIAL INSURANCE COMPANY OF AMERICA | $3K | — | $3K | 5.29% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| CNIC HEALTH SOLUTIONS INC EIN 71-0873411 CONTRACT ADMINISTRATOR | Contract Administrator Service code 13 | — | $35K |
| PHCS EIN 04-3138814 WRAP FEES | Other services Service code 49 | — | $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 | 45 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 1 | Continuation coverage (COBRA, retiree health). |
| Total participants (= "Plan participants" tile) | 46 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK | 37 | $19K |
| Vision | VISION SERVICE PLAN | 39 | $5K |
| Life insurance | PRUDENTIAL INSURANCE COMPANY OF AMERICA | 46 | $53K |
| Prescription drug | STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK | 37 | $19K |
| Stop-loss / reinsurancereinsurance | STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK | 37 | $19K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 46 | — |
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.