| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| CBIZ BENEFITS & INSURANCE SERVICES3 Filed as: CBIZ BENEFITS AND INS SERVICES INC | P.O. BOX 632886 CINCINNATI, OH 452632886 | HARTFORD LIFE AND ACCIDENT | $4K | — | $4K | 13.62% |
| HUB INTERNATIONAL MIDWEST LIMITED3 Filed as: HUB INTERNATIONAL INS. SVCES., INC. | 2375 EAST CAMELBACK ROAD, SUITE 250 PHOENIX, AZ 85016 | HARTFORD LIFE AND ACCIDENT | -$3 | — | -$3 | -0.01% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| BLUE CROSS BLUE SHIELD OF AZ EIN 86-0004538 CLAIMS ADMINISTRATOR | Claims processing Service code 12 | — | $73K |
| SIGNIFICA BENEFIT SERVICES EIN 23-2504308 CLAIMS ADMINISTRATOR | Claims processing Service code 12 | — | $14K |
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 | 118 | 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) | 118 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | BLUE CROSS BLUE SHIELD OF ARIZONA | 101 | $176K |
| Dental | DELTA DENTAL OF ARIZONA | 81 | $51K |
| Vision(2 contracts, 2 carriers) | BLUE CROSS BLUE SHIELD OF ARIZONA | 109 | $182K |
| Life insurance | HARTFORD LIFE AND ACCIDENT | 118 | $26K |
| Prescription drug | BLUE CROSS BLUE SHIELD OF ARIZONA | 101 | $176K |
| Stop-loss / reinsurancereinsurance | BLUE CROSS BLUE SHIELD OF ARIZONA | 101 | $176K |
| Other | HARTFORD LIFE AND ACCIDENT | 118 | $26K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 118 | — |
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.