| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| TIM LEAKE3 | 6403 NW GRAND BLVD, STE 101 OKLAHOMA CITY, OK 73162 | NATIONWIDE LIFE INSURANCE COMPANY | $35K | — | $35K | — |
| GROUP BENEFIT SERVICES INC3 Filed as: GROUP BENEFIT SERVICES, INC. | 1736 E SUNSHINE ST STE 200 SPRINGFIELD, MO 65804 | NATIONWIDE LIFE INSURANCE COMPANY | $17K | — | $17K | — |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| GROUP BENEFIT SERVICES, INC. EIN 43-1770779 PLAN ADMINISTRATOR | Plan Administrator; Recordkeeping and information management (computing, tabulating, data processing, etc.); Claims processing Service code 12 | 1736 E SUNSHINE ST STE 200 SPRINGFIELD, MO 65804 | $52K |
| THE SANDSTECH GROUP / CIGNA EIN 31-1418743 PPO NETWORK | Other fees Service code 99 | 1385 KEMPER MEADOW DRIVE CINCINNATI, OH 45240 | $32K |
| LINCOLN NATIONAL LIFE INSURANCE CO. EIN 22-0832760 LIFE INSURER | Other fees Service code 99 | 8801 INDIAN HILLS DRIVE OMAHA, NE 68114 | $15K |
| PHCS / MULTIPLAN EIN 13-3068979 PPO NETWORK | Other fees Service code 99 | 3345 MICHELSON DRIVE, STE. 200 IRVINE, CA 92612 | $7K |
| MANAGED CARE CONCEPTS EIN 86-0799129 UTILIZATION REVIEW | Other fees Service code 99 | 416 DONNELL ORANGE, TX 77630 | $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 | 174 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 174 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | NATIONWIDE LIFE INSURANCE COMPANY | 174 | $0 |
| Dental | NATIONWIDE LIFE INSURANCE COMPANY | 174 | $0 |
| Vision | NATIONWIDE LIFE INSURANCE COMPANY | 174 | $0 |
| Life insurance | NATIONWIDE LIFE INSURANCE COMPANY | 174 | $0 |
| Prescription drug | NATIONWIDE LIFE INSURANCE COMPANY | 174 | $0 |
| Stop-loss / reinsurancereinsurance | NATIONWIDE LIFE INSURANCE COMPANY | 174 | $0 |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 174 | — |
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."
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.