No insurance carriers on this filing. Self-funded welfare plans typically pay TPAs and PBMs through Schedule C, not Schedule A.
No brokers reported on this filing.
| Provider | Services | Address | Compensation |
|---|---|---|---|
| HCC LIFE INSURANCE STOP LOSS PREMIUM | Insurance services Service code 23 | 225 TOWNPARK DR, 350 213-660-1793 KENNESAW, GA 30144 | $122K |
| SOUTHERN BENEFITS ADMINISTRATOR INC EIN 59-6154877 PLAN ADMINISTRATOR | Plan Administrator Service code 14 | PO BOX 1449 GOODLETTSVILLE, TN 37070 | $118K |
| UMR PPO SERVICES | Insurance services Service code 23 | 115 W WAUSAU AVENUE WAUSAU, WI 54401 | $81K |
| GRAMLING & HAYA, CPA'S, PA EIN 59-1891796 PLAN AUDITOR | Accounting (including auditing) Service code 10 | P.O. BOX 290069 TAMPA, FL 33687 | $18K |
| SOUTHERN BENEFIT ADMINISTRATORS,INC EIN 59-6154877 PRINTING AND MAILING | Plan Administrator Service code 14 | P.O. BOX 1449 GOODLETSVILLE, TN 370701449 | $14K |
| SOUTHERN BENEFIT ADMINISTRATOR, INC EIN 59-6154877 ACTURIAL FEES | Actuarial Service code 11 | PO BOX 1449 GOODLETTSVILLE, TN 370701449 | $10K |
| VENABLE LAW FIRM, PA EIN 59-1824867 PLAN ATTORNEY | Legal Service code 29 | 7402 N 56TH ST,SUITE 380 TAMPA, FL 33617 | $9K |
| VIVEKA HEALTH ESTIMATOR TOOL KIT | Other fees Service code 99 | 104 W 14TH ST NEW YORK, NY 10011 | $4K |
| UNITED HEALTHCARE DISPUTE RESOLUTION | Other fees Service code 99 | 9700 HEALTH CARE LANE HOPKINS, MN 55343 | $599 |
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 | 168 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 8 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 176 | Active + retired/separated + beneficiaries. No dependents. |
No Schedule A insurance contracts on this filing — typical of fully self-funded plans, where the only headcount is the Form 5500 number above.
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."
No prospect flags tripped on this filing.