| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| DIVERSIFIED INSURANCE GROUP3 Filed as: DIVERSIFIED INSURANCE BENEFIT SVCS | 136 E. SOUTH TEMPLE #2300 SALT LAKE CITY, UT 84111 | CIGNA HEALTH AND LIFE INSURANCE COMPANY | $63K | — | $63K | 14.77% |
| DIVERSIFIED INSURANCE GROUP3 Filed as: DIVERSIFIED INSURANCE BENEFITS | 136 E. SOUTH TEMPLE #2300 SALT LAKE, UT 84111 | LIFE INSURANCE COMPANY OF NORTH AMERICA | $2K | $451 | $3K | 12.00% |
| NATIONAL BENEFIT CENTER3 | 6830 COCHRAN ROAD SOLON, OH 44139 | LIFE INSURANCE COMPANY OF NORTH AMERICA | — | $900 | $900 | 4.00% |
| DIVERSIFIED INSURANCE GROUP3 Filed as: DIVERSIFIED INSURANCE BENEFITS | 136 E. SOUTH TEMPLE #2300 SALT LAKE, UT 84111 | LIFE INSURANCE COMPANY OF NORTH AMERICA | $2K | $286 | $2K | 11.90% |
| NATIONAL BENEFIT CENTER3 | 6830 CHOCHRAN ROAD SOLON, OH 44139 | LIFE INSURANCE COMPANY OF NORTH AMERICA | — | $602 | $602 | 4.00% |
| DIVERSIFIED INSURANCE GROUP3 Filed as: DIVERSIFIED INSURANCE BENEFITS | 136 E. SOUTH TEMPLE #2300 SALT LAKE, UT 84111 | LIFE INSURANCE COMPANY OF NORTH AMERICA | $2K | $301 | $2K | 12.01% |
| NATIONAL BENEFIT CENTER3 | 6830 COCHRAN ROAD SOLON, OH 44139 | LIFE INSURANCE COMPANY OF NORTH AMERICA | — | $601 | $601 | 4.00% |
| DIVERSIFIED INSURANCE GROUP3 Filed as: DIVERSIFIED INSURANCE BENEFITS | 136 E. SOUTH TEMPLE #2300 SALT LAKE, UT 84111 | LIFE INSURANCE COMPANY OF NORTH AMERICA | $256 | $52 | $308 | 12.05% |
| NATIONAL BENEFIT CENTER3 | 6830 COCHRAN RD. SOLON, OH 44139 | LIFE INSURANCE COMPANY OF NORTH AMERICA | — | $102 | $102 | 3.99% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| AMERICAN SPECIALITY HEALTH SERVICE PROVIDER | Non-monetary compensation; Claims processing; Participant communication; Contract Administrator; Named fiduciary; Direct payment from the plan; Other services; Float revenue Service code 12 | 10221 WATERIDGE CIRCLE SUITE 201 SAN DIEGO, CA 92121 | $0 |
| CARECORE DBA EVICORE SERVICE PROVIDER | Float revenue; Participant communication; Direct payment from the plan; Other services; Named fiduciary; Contract Administrator; Claims processing; Non-monetary compensation Service code 12 | 400 BUCKWALTER PLACE BLVD BLUFFON, SC 29910 | $0 |
| CIGNA HEALTH & LIFE INS CO | Float revenue; Claims processing; Non-monetary compensation; Direct payment from the plan; Named fiduciary; Participant communication; Other services; Contract Administrator Service code 12 | — | $0 |
| CIGNA HEALTHY REWARDS VENDOR SERVICE PROVIDER | Participant communication; Contract Administrator; Float revenue; Other services; Claims processing; Direct payment from the plan; Named fiduciary; Non-monetary compensation Service code 12 | 4000 LUXOTTICA PLACE MASON, OH 45040 | $0 |
| MEDSOLUTIONS DBA EVICORE INC SERVICE PROVIDER | Direct payment from the plan; Named fiduciary; Participant communication; Other services; Claims processing; Non-monetary compensation; Contract Administrator; Float revenue Service code 12 | 730 COOL SPRINGS BLVD #800 FRANKLIN, TN 37067 | $0 |
| US BANK NATIONAL ASSOCIATION SERVICE PROVIDER | Float revenue; Non-monetary compensation; Direct payment from the plan; Named fiduciary; Participant communication; Contract Administrator; Other services; Claims processing Service code 12 | 800 NICHOLLET MALL MINNEAPLOIS, MN 55402 | $0 |
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 | 159 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 159 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | CIGNA HEALTH AND LIFE INSURANCE COMPANY | 259 | $424K |
| Dental | CIGNA HEALTH AND LIFE INSURANCE COMPANY | 259 | $424K |
| Vision | CIGNA HEALTH AND LIFE INSURANCE COMPANY | 259 | $424K |
| Life insurance | LIFE INSURANCE COMPANY OF NORTH AMERICA | 0 | $23K |
| Short-term disability | LIFE INSURANCE COMPANY OF NORTH AMERICA | 0 | $15K |
| Long-term disability | LIFE INSURANCE COMPANY OF NORTH AMERICA | 0 | $15K |
| Other | LIFE INSURANCE COMPANY OF NORTH AMERICA | 0 | $3K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 259 | — |
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.
Top carrier holds >85% of premium. If that carrier hits a rate increase, the entire plan moves.