| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| M3 INSURANCE SOLUTIONS INC3 Filed as: M3 INSURANCE SOLUTIONS, INC | P.O. BOX 8950 MADISON, WI 53708 | RELIASTAR LIFE INSURANCE COMPANY | $4K | — | $4K | 10.00% |
| BENE RE LLC3 | 5217 MONROE ST., STE. B TOLEDO, OH 43623 | RELIASTAR LIFE INSURANCE COMPANY | — | $3K | $3K | 8.00% |
| VAN EPPS, JAMES, H3 Filed as: VAN EPPS, JAMES | 10930 CRABAPPLE RD. STE 206 ROSWELL, GA 30075 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $564 | $94 | $658 | 6.48% |
| BLOCK, CHARLES, D3 Filed as: BLOCK, CHARLES | UNIT 208 648 VILLAGE PARK DR. WILMINGTON, NC 28405 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $564 | $94 | $658 | 6.48% |
| RIGGS COUNSELMAN MICHAELS & DOWNES3 Filed as: RIGGS COUNCILMAN MICHAELS | AND DOWNS, INC. 555 FAIRMOUNT AVE. BALTIMORE, MD 21286 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $413 | $1 | $414 | 4.07% |
| M3 INSURANCE SOLUTIONS INC3 Filed as: M3 INSURANCE SOLUTIONS, INC. | 828 JOHN NOLEN DR. MADISON, WI 53713 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $69 | — | $69 | 0.68% |
| BLOCK, CHARLES, D3 Filed as: BLOCK, CHARLES | 648 VILLAGE PARK DR., UNIT 208 WILMINGTON, NC 28405 | PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY | $686 | $67 | $753 | 12.72% |
| VAN EPPS, JAMES, H3 Filed as: VAN EPPS, JAMES | 10930 CRABAPPLE RD., STE 206 ROSWELL, GA 30075 | PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY | $686 | $66 | $752 | 12.71% |
| RIGGS COUNSELMAN MICHAELS & DOWNES3 Filed as: RIGGS COUNCILMAN MICHAELS | AND DOWNS, INC. 555 FAIRMOUNT AVE. BALTIMORE, MD 21286 | PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY | $405 | $1 | $406 | 6.86% |
| M3 INSURANCE SOLUTIONS INC3 Filed as: M3 INSURANCE SOLUTIONS, INC. | 828 JOHN NOLEN DR. MADISON, WI 53713 | PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY | $36 | — | $36 | 0.61% |
| NFP INSURANCE SERVICES INC3 Filed as: NFP INSURANCE SERVICES, INC | 1250 CAPITAL OF TEXAS HWY, BLDG 2, STE 125 AUSTIN, TX 78746 | PROVIDENT LIFE AND ACCIDENT INSURANCE COMPANY | — | $1 | $1 | 0.02% |
| VAN EPPS, JAMES, H3 Filed as: VAN EPPS, JAMES | 10930 CRABAPPLE RD., STE. 206 ROSEWELL, GA 30075 | FIRST UNUM LIFE INSURANCE COMPANY | $5 | — | $5 | 1.67% |
| BLOCK, CHARLES, D3 Filed as: BLOCK, CHARLES | 648 VILLAGE PARK DR., UNIT 208 WILMINGTON, NC 28405 | FIRST UNUM LIFE INSURANCE COMPANY | $5 | — | $5 | 1.67% |
| RIGGS COUNSELMAN MICHAELS & DOWNES3 Filed as: RIGGS COUNCILMAN MICHAELS | AND DOWNS, INC. 555 FAIRMOUNT AVE. BALTIMORE, MD 21286 | FIRST UNUM LIFE INSURANCE COMPANY | $4 | — | $4 | 1.34% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| FCE BENEFIT ADMINISTRATORS, INC. EIN 33-0330036 NONE | Contract Administrator Service code 13 | 1528 S. EL CAMINO REAL., SUITE 407 SAN MATEO, CA 94402 | $231K |
| ANTHEM LIFE INSURANCE COMPANY EIN 35-0980405 NONE | Claims processing; Other services; Contract Administrator; Recordkeeping and information management (computing, tabulating, data processing, etc.); Float revenue Service code 12 | — | $60K |
| M3 INSURANCE SOLUTIONS, INC. EIN 39-1141360 NONE | Insurance agents and brokers Service code 22 | 828 JOHN NOLEN DR., MADISON, WI 53713 | $57K |
| FIDUCIARY PLAN MANAGEMENT SERVICES EIN 46-3922133 NONE | Accounting (including auditing); Trustee (directed) Service code 10 | 1 ALAMADEN BLVD., SUITE 750 SAN JOSE, CA 95113 | $37K |
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 | 947 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 947 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Life insurance(3 contracts, 3 carriers) | ANTHEM LIFE INSURANCE COMPANY | 249 | $210K |
| Short-term disability | ANTHEM LIFE INSURANCE COMPANY | 249 | $204K |
| Long-term disability | ANTHEM LIFE INSURANCE COMPANY | 249 | $204K |
| Stop-loss / reinsurancereinsurance | ANTHEM LIFE INSURANCE COMPANY | 912 | $256K |
| Other(3 contracts, 3 carriers) | ANTHEM LIFE INSURANCE COMPANY | 275 | $250K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 912 | — |
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.