| 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 | $54K | — | $54K | 1.99% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 175 COLLEGE AVENUE SANTA ROSA, CA 95401 | CALIFORNIA PHYSICIANS SERVICE | $54K | $61 | $54K | 2.87% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 175 WEST COLLEGE AVENUE SANTA ROSA, CA 95401 | PRINCIPAL LIFE INSURANCE COMPANY | $20K | — | $20K | 4.41% |
| LEBHERZ INSURANCE SERVICES INC3 Filed as: LEBHERZ INSURANCE SERVICES, INC. | 1600 WEST HILLSDALE BOULEVARD SAN MATEO, CA 94402 | PRINCIPAL LIFE INSURANCE COMPANY | $13K | — | $13K | 3.00% |
| GEORGE PETERSEN INSURANCE AGENCY3 Filed as: GEORGE PETERSEN INS. AGENCY | 127 WEST COLLEGE AVENUE SANTA ROSA, CA 95402 | PRINCIPAL LIFE INSURANCE COMPANY | — | $7K | $7K | 1.45% |
| GEORGE PETERSEN INSURANCE AGENCY3 Filed as: GEORGE PETERSON INSURANCE AGENCY | 175 COLLEGE AVENUE SANTA ROSA, CA 95401 | BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY | $2K | — | $2K | 5.01% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 416 EAST STREET EUREKA, CA 95501 | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | $1K | — | $1K | 15.00% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 627 COLLEGE AVENUE SANTA ROSA, CA 95404 | DELTA DENTAL | $410 | — | $410 | 10.00% |
| ROBERT M NISSIM4 Filed as: ROBERT M. NISSIM | 103 FOUNTAINHEAD COURT MARTINEZ, CA 94553 | PRE-PAID LEGAL SERVICES, INC. DBA LEGALSHIELD | $424 | — | $424 | 12.34% |
| CORNELIUS J. BUTLER4 | 4254 DARDANELLES STREET SACRAMENTO, CA 95834 | PRE-PAID LEGAL SERVICES, INC. DBA LEGALSHIELD | $284 | — | $284 | 8.27% |
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 | 556 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 5 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 561 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(2 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN INC | 558 | $4.6M |
| Dental(2 contracts, 2 carriers) | PRINCIPAL LIFE INSURANCE COMPANY | 1,072 | $453K |
| Life insurance(2 contracts, 2 carriers) | PRINCIPAL LIFE INSURANCE COMPANY | 1,072 | $488K |
| Short-term disability | PRINCIPAL LIFE INSURANCE COMPANY | 1,072 | $448K |
| Long-term disability | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | 11 | $7K |
| Prescription drug(2 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN INC | 558 | $4.6M |
| Other(2 contracts, 2 carriers) | BLUE SHIELD OF CALIFORNIA LIFE AND HEALTH INSURANCE COMPANY | 630 | $43K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 1,072 | — |
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."
No prospect flags tripped on this filing.