| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| DOMINIUM BENEFITS, LLC3 | 3500 LENOX ROAD NE, SUITE 1600 ATLANTA, GA 30326 | BLUE CROSS BLUE SHIELD OF FLORIDA | $64K | — | $64K | 3.00% |
| DOMINIUM BENEFITS, LLC3 | 3500 LENOX ROAD NE, SUITE 1600 ATLANTA, GA 30326 | HEALTH OPTIONS, INC. | $23K | — | $23K | 3.00% |
| INTEGRO INSURANCE BROKERS3 Filed as: DOMINIUM, A DIVISION OF INTEGRO USA | 3333 PIEDMONT ROAD, SUITE 1400 ATLANTA, GA 30305 | RELIANCE STANDARD LIFE INSURANCE COMPANY | $39K | — | $39K | 20.00% |
| DOMINIUM BENEFITS, LLC3 | 3500 LENOX ROAD NE, SUITE 1600 ATLANTA, GA 30326 | RELIANCE STANDARD LIFE INSURANCE COMPANY | $594 | — | $594 | 2.00% |
| INTEGRO INSURANCE BROKERS3 Filed as: DOMINIUM, A DIVISION OF INTEGRO USA | 3333 PIEDMONT ROAD, SUITE 1400 ATLANTA, GA 30305 | RELIANCE STANDARD LIFE INSURANCE COMPANY | $874 | — | $874 | 20.00% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| RELIANCE STANDARD LIFE INSURANCE CO EIN 36-0883760 CONTRACT ADMINISTRATOR | Contract Administrator Service code 13 | — | $11K |
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 | 250 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 250 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(2 contracts, 2 carriers) | BLUE CROSS BLUE SHIELD OF FLORIDA | 160 | $2.9M |
| Dental | RELIANCE STANDARD LIFE INSURANCE COMPANY | 127 | $30K |
| Vision(2 contracts) | RELIANCE STANDARD LIFE INSURANCE COMPANY | 277 | $48K |
| Long-term disability | RELIANCE STANDARD LIFE INSURANCE COMPANY | 182 | $195K |
| Prescription drug(2 contracts, 2 carriers) | BLUE CROSS BLUE SHIELD OF FLORIDA | 160 | $2.9M |
| Other | RELIANCE STANDARD LIFE INSURANCE COMPANY | 250 | $4K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 277 | — |
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."
Multiple-employer welfare arrangement. Specific regulatory and compliance context; specific consultant niche.