| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| GEORGE PETERSEN INSURANCE AGENCY3 | 175 WEST COLLEGE AVENUE SANTA ROSA, CA 95401 | KAISER FOUNDATION HEALTH PLAN, INC. | $4K | $0 | $4K | 0.75% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 175 WEST COLLEGE AVENUE SANTA ROSA, CA 95401 | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | $2K | $0 | $2K | 3.13% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 175 WEST COLLEGE AVENUE SANTA ROSA, CA 95401 | PRINCIPAL LIFE INSURANCE COMPANY | $663 | — | $663 | 7.97% |
| AMWINS4 Filed as: AMWINS CONNECT INSURANCE SERVICES | 2677 NORTH MAIN STREET, SUITE 800 SANTA ANA, CA 92705 | PRINCIPAL LIFE INSURANCE COMPANY | — | $253 | $253 | 3.04% |
| ROBERT M NISSIM4 Filed as: ROBERT M. NISSIM | 1038 BANCROFT ROAD CONCORD, CA 94518 | PRE-PAID LEGAL SERVICES, INC. DBA LEGALSHIELD | $77 | — | $77 | 8.22% |
| GEORGE PETERSEN INSURANCE AGENCY3 | PO BOX 3539 SANTA ROSA, CA 95402 | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | $131 | — | $131 | 15.01% |
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 | 490 | 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) | 490 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | KAISER FOUNDATION HEALTH PLAN, INC. | 414 | $492K |
| Dental | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | 845 | $60K |
| Vision | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | 845 | $60K |
| Life insurance | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | 490 | $0 |
| Short-term disability | PRINCIPAL LIFE INSURANCE COMPANY | 81 | $8K |
| Long-term disability | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | 13 | $873 |
| Prescription drug | KAISER FOUNDATION HEALTH PLAN, INC. | 414 | $492K |
| Other(2 contracts, 2 carriers) | PRE-PAID LEGAL SERVICES, INC. DBA LEGALSHIELD | 490 | $937 |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 845 | — |
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.