| 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 | $60K | $90 | $60K | 1.97% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 175 WEST COLLEGE AVENUE SANTA ROSA, CA 95401 | UNITEDHEALTHCARE INSURANCE COMPANY | $7K | $8K | $15K | 0.66% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 175 WEST COLLEGE AVENUE SANTA ROSA, CA 95401 | PRINCIPAL LIFE INSURANCE COMPANY | $10K | $1K | $11K | 8.98% |
| AMWINS3 Filed as: LISI, LLC | 1600 WEST HILLSDALE BOULEVARD SUITE 201 SAN MATEO, CA 94402 | PRINCIPAL LIFE INSURANCE COMPANY | $4K | $1K | $5K | 4.05% |
| GEORGE PETERSEN INSURANCE AGENCY3 | 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 | $409 | $0 | $409 | 10.01% |
| ROBERT M NISSIM4 Filed as: ROBERT M. NISSIM | 1038 BANCROFT ROAD CONCORD, CA 94518 | PRE-PAID LEGAL SERVICES, INC. DBA LEGALSHIELD | $578 | $0 | $578 | 16.05% |
| CORNELIUS J. BUTLER4 | 4254 DARDANELLES STREET SACRAMENTO, CA 95834 | PRE-PAID LEGAL SERVICES, INC. DBA LEGALSHIELD | $62 | $0 | $62 | 1.72% |
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 | 779 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 2 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 781 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(2 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN INC | 1,452 | $5.4M |
| Dental(2 contracts, 2 carriers) | UNITEDHEALTHCARE INSURANCE COMPANY | 1,452 | $2.3M |
| Vision | UNITEDHEALTHCARE INSURANCE COMPANY | 1,452 | $2.3M |
| Life insurance(2 contracts, 2 carriers) | UNITEDHEALTHCARE INSURANCE COMPANY | 1,452 | $2.5M |
| Short-term disability | PRINCIPAL LIFE INSURANCE COMPANY | 385 | $119K |
| Long-term disability | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | 12 | $8K |
| Prescription drug(2 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN INC | 1,452 | $5.4M |
| Other(3 contracts, 3 carriers) | PRINCIPAL LIFE INSURANCE COMPANY | 603 | $133K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 1,452 | — |
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.