| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| GEORGE PETERSEN INSURANCE AGENCY3 Filed as: GEORGE PETERSEN INS. AGENCY | 175 WEST COLLEGE AVENUE SANTA ROSA, CA 95401 | KAISER FOUNDATION HEALTH PLAN INC | $50K | — | $50K | 1.95% |
| GEORGE PETERSEN INSURANCE AGENCY3 Filed as: GEORGE PETERSEN INS. AGENCY | 175 COLLEGE AVENUE SANTA ROSA, CA 95401 | CALIFORNIA PHYSICIANS SERVICE | $54K | $72 | $54K | 3.00% |
| GEORGE PETERSEN INSURANCE AGENCY3 Filed as: GEORGE PETERSEN INS. AGENCY | PO BOX 3539 SANTA ROSA, CA 95402 | PRINCIPAL LIFE INSURANCE COMPANY | $18K | — | $18K | 4.26% |
| LEBHERZ INSURANCE SERVICES INC3 Filed as: LEBHERZ INSURANCE SERVICES, INC. | 1600 WEST HILLSDALE BOULEVARD SAN MATEO, CA 94402 | PRINCIPAL LIFE INSURANCE COMPANY | $13K | $2K | $15K | 3.49% |
| GEORGE PETERSEN INSURANCE AGENCY3 Filed as: GEORGE PETERSON INS. AGENCY, INC. | 175 COLLEGE AVENUE SANTA ROSA, CA 95401 | BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY | $2K | — | $2K | 5.31% |
| GEORGE PETERSEN INSURANCE AGENCY3 Filed as: GEORGE PETERSEN INS. AGENCY | 416 EAST STREET EUREKA, CA 95501 | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | $987 | — | $987 | 15.01% |
| GEORGE PETERSEN INSURANCE AGENCY3 Filed as: GEORGE PETERSEN INS. AGENCY | 627 COLLEGE AVENUE SANTA ROSA, CA 95404 | DELTA DENTAL | $429 | — | $429 | 10.01% |
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 | 588 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 6 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 1 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 595 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(2 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN INC | 528 | $4.4M |
| Dental(2 contracts, 2 carriers) | PRINCIPAL LIFE INSURANCE COMPANY | 988 | $422K |
| Life insurance(2 contracts, 2 carriers) | PRINCIPAL LIFE INSURANCE COMPANY | 988 | $446K |
| Short-term disability | PRINCIPAL LIFE INSURANCE COMPANY | 988 | $417K |
| Long-term disability | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | 11 | $7K |
| Prescription drug(2 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN INC | 528 | $4.4M |
| Other | BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY | 569 | $29K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 988 | — |
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.