| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| USI INSURANCE SERVICES LLC3 | 100 SUMMIT LAKE DR, STE 400 VALHALLA, NY 10595 | DELTA DENTAL OF PENNSYLVANIA | $3K | — | $3K | 10.00% |
| USI INSURANCE SERVICES LLC3 | PO BOX 61007 VIRGINIA BEACH, VA 23466 | FIDELITY SECURITY LIFE INSURANCE COMPANY | $537 | — | $537 | 6.76% |
| USI INSURANCE SERVICES LLC3 | NATIONAL ACCOUNTING CENTER VIRGINIA BEACH, VA 23462 | FIDELITY SECURITY LIFE INSURANCE COMPANY | $295 | — | $295 | 3.72% |
| PAYCHEX INSURANCE AGENCY, INC.3 Filed as: PAYCHEX AGENCY INC. | P.O. BOX 948 HENRIETTA, NY 14467 | COMPANION LIFE INSURANCE COMPANY | $184 | — | $184 | 15.01% |
| CONSOLIDATED BENEFITS INC3 Filed as: CONSOLIDATED BENEFITS INC. | 2500 ELMERTON AVE HARRISBURG, PA 17110 | COMPANION LIFE INSURANCE COMPANY | $92 | — | $92 | 7.50% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| PCI INSURANCE AGENCY BROKER | Insurance agents and brokers Service code 22 | 417 WALNUT STREET HARRISBURG, PA 17101 | $24K |
| HIGHMARK EIN 23-1294723 ADMIN | Claims processing Service code 12 | — | $23K |
| THE BENECON GROUP EIN 23-1315351 BROKER | Insurance agents and brokers Service code 22 | — | $17K |
| CONNECTCARE3 EIN 26-1768616 PATIENT ADVOCATE | Other services Service code 49 | — | $5K |
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 | 95 | 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) | 95 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Dental | DELTA DENTAL OF PENNSYLVANIA | 153 | $33K |
| Vision | FIDELITY SECURITY LIFE INSURANCE COMPANY | 141 | $8K |
| Life insurance | COMPANION LIFE INSURANCE COMPANY | 95 | $1K |
| Stop-loss / reinsurancereinsurance | EVEREST REINSURANCE COMPANY | 83 | $208K |
| Other | COMPANION LIFE INSURANCE COMPANY | 95 | $1K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 153 | — |
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.