| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| EDWARD CHICOSKI III3 Filed as: EDWARD J CHICOSKI | 301 ALBANY TURNPIKE CANTON, CT 06019 | HARTFORD LIFE AND ACCIDENT | $1K | — | $1K | 0.40% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| ANTHEM INSURANCE COMPANIES EIN 35-0781558 NONE | Float revenue; Claims processing; Contract Administrator Service code 12 | — | $2.5M |
| REINHART, BOERNER, VAN DEUREN EIN 39-1126909 NONE | Legal Service code 29 | — | $148K |
| MILLIMAN INC. EIN 91-0675641 NONE | Consulting fees Service code 70 | — | $134K |
| SLEVIN & HART, P.C. EIN 52-1708613 NONE | Legal Service code 29 | — | $118K |
| BENESYS, INC EIN 55-0772752 NONE | Plan Administrator Service code 14 | — | $99K |
| DELTA DENTAL OF PENNSYLVANIA EIN 23-1667011 NONE | Plan Administrator; Claims processing; Direct payment from the plan Service code 12 | — | $97K |
| CALIBRE CPA GROUP, PLLC EIN 47-0900880 NONE | Accounting (including auditing) Service code 10 | — | $59K |
| KIMBERLY ROGERS EIN 55-0393244 EMPLOYEE | Employee (plan) Service code 30 | — | $40K |
| APRIL SMITH EIN 55-0393244 EMPLOYEE | Employee (plan) Service code 30 | — | $37K |
| D STREET LLC EIN 20-4337584 NONE | Other fees Service code 99 | — | $35K |
| GROUP VISION SERVICES EIN 26-3323202 NONE | Claims processing Service code 12 | — | $17K |
| DEANN CARPENTER EIN 55-0393244 EMPLOYEE | Employee (plan) Service code 30 | — | $13K |
| JATINA DYESS EIN 55-0393244 EMPLOYEE | Employee (plan) Service code 30 | — | $10K |
| UNITED ACTUARIAL EIN 35-2156428 NONE | Actuarial Service code 11 | — | $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 | 2,204 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 734 | Continuation coverage (COBRA, retiree health). |
| Total participants (= "Plan participants" tile) | 2,938 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Life insurance | HARTFORD LIFE AND ACCIDENT | 2,967 | $282K |
| Other | HARTFORD LIFE AND ACCIDENT | 2,967 | $282K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 2,967 | — |
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.