| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES, INC. | 575 ANTON BLVD, STE 610 COSTA MESA, CA 92626 | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | $37K | — | $37K | 1.92% |
| AMWINS3 Filed as: LISI, INC. | 1600 WEST HILLSDALE BLVD SAN MATEO, CA 94402 | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | — | $24K | $24K | 1.23% |
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES, INC. | 3000 W MACARTHUR BLVD, STE 320 SANTA ANA, CA 92704 | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | $16K | — | $16K | 0.86% |
| AMWINS3 Filed as: LISI, INC. | 1600 WEST HILLSDALE BLVD, STE 201 SAN MATEO, CA 94403 | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | — | $10K | $10K | 0.52% |
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES, INC. | 3000 W MACARTHUR BLVD, STE 320 SANTA ANA, CA 92704 | UNITED CONCORDIA INSURANCE COMPANY | $14K | — | $14K | 9.98% |
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES, INC. | 3000 W MACARTHUR BLVD, STE 320 SANTA ANA, CA 92704 | UNITED CONCORDIA DENTAL PLANS OF CALIFORNIA, INC. | $120 | — | $120 | 9.97% |
No Schedule C service providers reported on this filing.
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 | 120 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 0 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 120 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | 319 | $1.9M |
| Dental(3 contracts, 3 carriers) | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | 343 | $2.1M |
| Vision | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | 319 | $1.9M |
| Life insurance | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | 319 | $1.9M |
| Long-term disability | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | 319 | $1.9M |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 343 | — |
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."
Top carrier holds >85% of premium. If that carrier hits a rate increase, the entire plan moves.