| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| USI INSURANCE SERVICES LLC3 Filed as: KIBBLE & PRENTICE HOLDING COMPANY | — | BLUECROSS BLUESHIELD | $6K | — | $6K | 0.58% |
| HUB INTERNATIONAL MIDWEST LIMITED3 | — | BLUECROSS BLUESHIELD | $3K | — | $3K | 0.31% |
| USI INSURANCE SERVICES LLC3 Filed as: KIBBLE & PRENTICE HOLDING | PO BOX 62949 VIRGINI BEACH, VA 23466 | LIFE INSURANCE COMPANY OF NORTH AMERICA | — | $442 | $442 | 1.10% |
| USI INSURANCE SERVICES LLC3 Filed as: KIBBLE & PRENTICE HOLDING | PO BOX 62949 VIFGINIA BEACH, VA 23466 | LIFE INSURANCE COMPANY OF NORTH AMERICA | — | $359 | $359 | 1.44% |
| USI INSURANCE SERVICES LLC3 Filed as: KIBBLE & PRENTICE HOLDING | PO BOX 62949 VIRGINIA BEACH, VA 23466 | LIFE INSURANCE COMPANY OF NORTH AMERICA | — | $137 | $137 | 0.93% |
| RALPH SOULBY3 | 817 FARRAGUT COMMONS DR. KNOXVILLE, TN 37934 | METROPOLITAN LIFE INSURANCE COMPANY | $1K | — | $1K | 18.23% |
| USI INSURANCE SERVICES LLC3 Filed as: KIBBLE & PRENTICE HOLDING | PO BOX 62949 VIRGINA BEACH, VA 23466 | LIFE INSURANCE COMPANY OF NORTH AMERICA | — | $60 | $60 | 1.14% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| HUB INTERNATIONAL MIDWEST LIMITED BROKER | Insurance agents and brokers Service code 22 | 6100 S. YALE, STE 1900 TULSA, OK 74136 | $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 | 157 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 157 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | BLUECROSS BLUESHIELD | 275 | $1.1M |
| Dental | BLUECROSS BLUESHIELD | 275 | $1.1M |
| Vision | VISION SERVICE PLAN | 143 | $16K |
| Life insurance(3 contracts, 2 carriers) | LIFE INSURANCE COMPANY OF NORTH AMERICA | 207 | $53K |
| Short-term disability(2 contracts, 2 carriers) | LIFE INSURANCE COMPANY OF NORTH AMERICA | 157 | $33K |
| Long-term disability(2 contracts, 2 carriers) | LIFE INSURANCE COMPANY OF NORTH AMERICA | 157 | $22K |
| Other | METROPOLITAN LIFE INSURANCE COMPANY | 37 | $8K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 275 | — |
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."
Top carrier holds >85% of premium. If that carrier hits a rate increase, the entire plan moves.
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.