| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| BENEFIT CAPTIVE RE3 Filed as: BENEFIT CAPTIVE RE LLC | 5636 FORD ST NORWALK, IA 50211 | FAIRMONT | $42K | $9K | $51K | 15.05% |
| GROUP & PENSION ADMINISTRATORS INC5 Filed as: GROUP & PENSION ADMINISTRATORS, INC | 12770 MERIT DRIVE STE 200 DALLAS, TX 75251 | FAIRMONT | — | $38K | $38K | 11.18% |
| AIG BENEFIT SOLUTIONS5 | MEDICAL EXCESS 3600 ROUTE 66 NEPTUNE, NJ 07754 | FAIRMONT | — | $17K | $17K | 5.14% |
| PHCS5 Filed as: MULTI PLAN INC | 115 FIFTH AVENUE NEW YORK, NY 10003 | FAIRMONT | — | $9K | $9K | 2.68% |
| ELAP SERVICE LLC5 | 17 BROOKWOOD DRIVE NEWMAN, GA 30263 | FAIRMONT | — | $1K | $1K | 0.36% |
| TELADOC5 Filed as: TELADOC INC | 17304 PRESTON ROAD STE 730 DALLAS, TX 75252 | FAIRMONT | — | $263 | $263 | 0.08% |
| FILICE INSURANCE AGENCY3 Filed as: RON FILICE ENTERPRISES INC | 738 N 1ST ST STE 202 SAN JOSE, CA 95112 | SUN LIFE ASSURANCE COMPANY OF CANADA | $5K | — | $5K | 4.61% |
| FILICE INSURANCE AGENCY3 Filed as: RON FILICE ENTERPRISES | 738 N 1ST STE 202 SAN JOSE, CA 95112 | VISION SERVICE PLAN | $1K | — | $1K | 10.00% |
| RSI INSURANCE BROKERS INC3 | 2801 BRISTOL ST COSTA MESA, CA 92626 | COLONIAL LIFE & ACCIDENT INSURANCE COMPANY | $133 | — | $133 | 2.59% |
| ANDREA MARIE TIERCE3 | 2204 PLEASANTWOOD LN ESCONDIDO, CA 92026 | COLONIAL LIFE & ACCIDENT INSURANCE COMPANY | $39 | — | $39 | 0.76% |
| BENEFITS DR INC3 | 6785 W 7750 N AMERICAN FORK, UT 84003 | COLONIAL LIFE & ACCIDENT INSURANCE COMPANY | $34 | — | $34 | 0.66% |
| CALIFORNIA INSURANCE ADVOCATES INC3 | 41960 AVENIDA DE ANITA TEMECULA, CA 92592 | COLONIAL LIFE & ACCIDENT INSURANCE COMPANY | $33 | — | $33 | 0.64% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| BENEFIT CAPTIVE RE, LLC EIN 26-2531836 INSURANCE AGENT | Insurance agents and brokers Service code 22 | 5636 FORD ST NORWALK, IA 50211 | $51K |
| GROUP & PENSION ADMINISTRATORS, INC EIN 75-1617587 PLAN ADMIN | Contract Administrator Service code 13 | 12770 MERIT DRIVE STE 200 DALLAS, TX 75251 | $38K |
| AIG BENEFIT SOLUTIONS EIN 25-0687550 CLAIM PROCESSING | Claims processing Service code 12 | MEDICAL EXCESS 3600 ROUTE 66 NEPTUNE, NJ 07754 | $17K |
| MULTI PLAN INC EIN 13-3068979 | Insurance services Service code 23 | 115 FIFTH AVENUE NEW YORK, NY 10003 | $9K |
| RON FILLCE ENTERPRISES, INC EIN 77-0261203 INSURANCE AGENT | Insurance agents and brokers Service code 22 | 738 N 1ST ST STE 202 SAN JOSE, CA 95112 | $6K |
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 | 99 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 99 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(2 contracts, 2 carriers) | FAIRMONT | 101 | $344K |
| Dental | SUN LIFE ASSURANCE COMPANY OF CANADA | 171 | $112K |
| Vision | VISION SERVICE PLAN | 113 | $11K |
| Life insurance | SUN LIFE ASSURANCE COMPANY OF CANADA | 171 | $112K |
| Short-term disability | SUN LIFE ASSURANCE COMPANY OF CANADA | 171 | $112K |
| Stop-loss / reinsurancereinsurance(2 contracts, 2 carriers) | FAIRMONT | 101 | $344K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 171 | — |
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."
Broker compensation exceeds 5% of premium. Either a small-plan minimum-fee dynamic or an inefficient broker structure ripe for a counter-bid.
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.