| 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 | $61K | $0 | $61K | 2.04% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 175 COLLEGE AVENUE SANTA ROSA, CA 95401 | CALIFORNIA PHYSICIANS' SERVICE | $64K | $65 | $64K | 3.00% |
| GEORGE PETERSEN INSURANCE AGENCY3 Filed as: GEORGE PETERSON INSURANCE AGENCY | 175 WEST COLLEGE AVENUE SANTA ROSA, CA 95401 | PRINCIPAL LIFE INSURANCE COMPANY | $21K | $5K | $26K | 5.32% |
| LEBHERZ INSURANCE SERVICES INC3 Filed as: LEBHERZ INSURANCE SERVICES, INC. | 1600 WEST HILLSDALE BOULEVARD SAN MATEO, CA 94402 | PRINCIPAL LIFE INSURANCE COMPANY | $14K | $2K | $17K | 3.50% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 175 COLLEGE AVENUE SANTA ROSA, CA 95401 | BLUE SHIELD OF CALIFORNIA LIFE HEALTH INSURANCE COMPANY | $2K | $0 | $2K | 5.00% |
| GEORGE PETERSEN INSURANCE AGENCY3 Filed as: GEORGE PETERSON INSURANCE AGENCY | 416 EAST STREET EUREKA, CA 95501 | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | $1K | $0 | $1K | 15.00% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 627 COLLEGE AVENUE SANTA ROSA, CA 95404 | DELTA DENTAL | $524 | $0 | $524 | 10.01% |
| ROBERT M NISSIM3 Filed as: ROBERT M. NISSIM | 1038 BANCROFT ROAD CONCORD, CA 94518 | PRE-PAID LEGAL SERVICES, INC. DBA LEGALSHIELD | $249 | $0 | $249 | 10.63% |
| CORNELIUS J. BUTLER3 | 4254 DARDANELLES STREET SACRAMENTO, CA 95834 | PRE-PAID LEGAL SERVICES, INC. DBA LEGALSHIELD | $93 | $0 | $93 | 3.97% |
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 | 645 | 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) | 645 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(2 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN INC | 413 | $5.1M |
| Dental(2 contracts, 2 carriers) | PRINCIPAL LIFE INSURANCE COMPANY | 1,080 | $489K |
| Life insurance(2 contracts, 2 carriers) | PRINCIPAL LIFE INSURANCE COMPANY | 1,080 | $524K |
| Short-term disability | PRINCIPAL LIFE INSURANCE COMPANY | 1,080 | $483K |
| Long-term disability | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | 12 | $8K |
| Prescription drug(2 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN INC | 413 | $5.1M |
| Other(3 contracts, 3 carriers) | PRINCIPAL LIFE INSURANCE COMPANY | 1,080 | $526K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 1,080 | — |
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.