| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| HCC LIFE INSURANCE COMPANY | 225 TOWNPARK DRIVE, SUITE 350 KENNESAW, GA 301445509 | HCC LIFE INSURANCE COMPANY | $231K | — | $231K | — |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| HUMANA EIN 61-1041514 MEDICAL CLAIMS ADMIN | Claims processing Service code 12 | 101 EAST MAIN STREET LOUISVILLE, KY 40202 | $1.6M |
| BENESYS INC EIN 38-2383171 PLAN ADMINISTRATOR | Plan Administrator Service code 14 | 700 TOWER DRIVE STE 300 TROY, MI 48098 | $310K |
| CENTERS FOR MEDICARE & MEDICAID SER TRANSITIONAL REINSURANCE | Other fees Service code 99 | 7500 SECURITY BOULEVARD BALTIMORE, MD 21244 | $55K |
| BUCK CONSULTANTS EIN 13-3954297 ACTUARY | Actuarial Service code 11 | 231 S. BEMISON, SUITE 400 ST LOUIS, MO 63105 | $52K |
| ENVISION EIN 05-0570786 PRESCRIPTION CLAIMS ADMIN | Claims processing Service code 12 | 2181 E. AURORA RD, SUITE 201 TWINSBURG, OH 44087 | $50K |
| HARTFORD EIN 13-3317783 MEDICAL CLAIMS ADMIN | Claims processing Service code 12 | ONE HARTFORD PLAZA HARTFORD, CT 06155 | $46K |
| WILSON KOZICKI & GWYNN EIN 55-0526247 AUDITOR | Accounting (including auditing) Service code 10 | 32-20TH STREET, SUITE 300 WHEELING, WV 26003 | $37K |
| MANNING & NAPIER EIN 16-0095736 INVESTMENT MANAGER | Investment management Service code 28 | 290 WOODCLIFF DRIVE FAIRPORT, NY 14450 | $29K |
| CIGNA HEALTH AND LIFE INSURANCE CO EIN 59-1031071 MEDICAL CLAIMS ADMIN | Claims processing Service code 12 | PO BOX 644546 PITTSBURGH, PA 15264 | $24K |
| HEALTH DESIGN ENTERPRISE EIN 38-3607439 MEDICAL CLAIMS ADMIN | Claims processing Service code 12 | 1550 EAST BELTLINE SE, SUITE 175 GRAND RAPIDS, MI 49506 | $23K |
| DELTA DENTAL EIN 55-0523124 MEDICAL CLAIMS ADMIN | Claims processing Service code 12 | ONE DELTA DRIVE MECHANICSBURG, PA 17055 | $20K |
| MACALA, GORE & PIATT EIN 34-1933033 ATTORNEY | Legal Service code 29 | 601 SOUTH MAIN STREET NORTH CANTON, OH 44720 | $20K |
| RUBLE INSURANCE EIN 20-4632562 INSURANCE SERVICES | Insurance services Service code 23 | 605 GREENE STREET NEWPORT, OH 45768 | $17K |
| AMERICAN GRAPHICS PRINTING COMPANY EIN 38-2090931 PRINTING SERVICES | Copying and duplicating Service code 36 | 34895 GROESBECK HWY CLINTON TOWNSHIP, MI 48035 | $14K |
| HEALTHLY LIFE SCREENINGS LLC EIN 26-3565825 MEDICAL CLAIMS ADMIN | Claims processing Service code 12 | 2855 W. MARKET STREET SUITE 204 FAIRLAWN, OH 49506 | $11K |
| SEGAL ADVISORS EIN 13-1835864 INVESTMENT ADVISOR | Investment advisory (plan) Service code 27 | PO BOX 4142 CHURCH STREET STATION NEW YORK, NY 10261 | $10K |
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 | 628 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 300 | Continuation coverage (COBRA, retiree health). |
| Total participants (= "Plan participants" tile) | 928 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Stop-loss / reinsurancereinsurance | HCC LIFE INSURANCE COMPANY | 928 | $0 |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 928 | — |
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.