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 |
|---|---|---|---|
| EXPRESS SCRIPTS PRESCRIPTION SERVICES | Other fees Service code 99 | 1 EXPRESS WAY ST. LOUIS, MO 63121 | $321K |
| SOUTHERN BENEFITS ADMINISTRATOR INC EIN 59-6154877 PLAN ADMINISTRATOR | Actuarial; Claims processing; Plan Administrator; Contract Administrator Service code 11 | PO BOX 1449 GOODLETTSVILLE, TN 37070 | $125K |
| UMR PPO SERVICES | Insurance services Service code 23 | 115 W WAUSAU AVENUE WAUSAU, WI 54401 | $55K |
| THE SEGAL COMPANY EIN 13-1975125 MEDICAL CLAIMS CONSULTANT | Consulting (general) Service code 16 | 101 NORTH WACKER DRIVE CHICAGO, IL 606061724 | $45K |
| CIGNA BEHAVIORAL HEALTH CLAIMS CONSULTING | Consulting (general) Service code 16 | 11095 VIKING DR 800-433-5768 EDEN PRAIRIE, MN 55344 | $24K |
| GRAMLING & HAYA, CPA'S, PA EIN 59-1891796 AUDIT & TAX PREPARATION | Accounting (including auditing) Service code 10 | P.O. BOX 290069 TAMPA, FL 33687 | $19K |
| UNITED MEMBERS INSURANCE LIABILITY INSURANCE | Insurance agents and brokers Service code 22 | 6826 W LINEBAUGH AVE 813-265-2300 TAMPA, FL 33625 | $9K |
| OUT OF NETWORK SAVINGS PROGRAM PPO FEES | Insurance services Service code 23 | P.O. BOX 637268 CINNCINATI, OH 46263 | $7K |
| VENABLE LAW FIRM, PA EIN 59-1824867 LEGAL SERVICES | Legal Service code 29 | 7402 N 56TH ST,SUITE 380 TAMPA, FL 33617 | $7K |
| SOUTHERN BENEFIT ADMINISTRATORS,INC EIN 59-6154877 PRINTING & POSTAGE | Contract Administrator; Copying and duplicating Service code 13 | P.O. BOX 1449 GOODLETSVILLE, TN 370701449 | $4K |
| EBERTS AND HARRISON, INC BONDING | Insurance agents and brokers Service code 22 | 1604 RIDGESIDE DR, 203 301-596-3940 MT. AIRY, MD 21771 | $3K |
| UNITED HEALTHCARE -PPO PPO SERVICES | Insurance services Service code 23 | — | $3K |
| CONNECTICUT GENERAL LIFE INS CO EIN 06-0303370 CLAIMS MANAGEMENT & PRICI | Claims processing Service code 12 | 5089 COLLECTION CENTER DR CHICAGO, IL 606930050 | $0 |
| MEDICAL EXCESS STOP LOSS INSURANCE | Insurance services Service code 23 | P.O. BOX 842173 LOS ANGELES, CA 900842173 | $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 | 191 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 16 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 207 | 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.