| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| USI INSURANCE SERVICES LLC3 Filed as: USI INSURANCE SERVICES NORTHWEST | 975 OAK STREET, SUITE 900 EUGENE, OR 97401 | PACIFICSOURCE HEALTH PLANS | $40K | $0 | $40K | 3.10% |
| USI INSURANCE SERVICES LLC3 | PO BOX 62949 VIRGINIA BEACH, VA 23466 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $8K | $5K | $12K | 19.06% |
| USI INSURANCE SERVICES LLC3 Filed as: USI INSURANCE SERVICES NORTHWEST | 975 OAK STREET, SUITE 900 EUGENE, OR 97401 | WILLAMETTE DENTAL INSURANCE, INC. | $2K | $0 | $2K | 5.00% |
| USI INSURANCE SERVICES LLC3 Filed as: USI INSURANCE SERVICES NORTHWEST | 601 UNION STREET, SUITE 1000 SEATTLE, WA 98101 | LIFEMAP ASSURANCE COMPANY | $823 | $557 | $1K | 8.37% |
| MARCI MARIE OTIS3 Filed as: MARCI MARIE OTIX | 200 JULINA LANE ROSEBURG, OR 97471 | AFLAC | $483 | $13 | $496 | 5.49% |
| CAROL A. KENYON3 | 1645 CLEVELAND HILL ROAD ROSEBURG, OR 97471 | AFLAC | $291 | $9 | $300 | 3.32% |
| JEROMY E. CILLEY3 | 2683 EAST WILSHIRE DRIVE EUGENE, OR 97405 | AFLAC | $130 | $4 | $134 | 1.48% |
| USI INSURANCE SERVICES LLC3 Filed as: USI INSURANCE SERVICES NORTHWEST | 975 OAK STREET, SUITE 900 EUGENE, OR 97401 | AFLAC | $121 | $0 | $121 | 1.34% |
| TYLER M. OTIS3 | 200 JULINA LANE ROSEBURG, OR 97471 | AFLAC | $69 | $0 | $69 | 0.76% |
| RICHARD E. SYFERT3 | 86195 PANORAMA ROAD SPRINGFIELD, OR 97478 | AFLAC | $32 | $0 | $32 | 0.35% |
| CHRISTOPHER EDWARD RUSSELL3 Filed as: CHRISTOPHER E. RUSSELL AND AGENTS | 3333 SHELTON AVENUE EUGENE, OR 97405 | AFLAC | $19 | $0 | $19 | 0.21% |
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 | 103 | 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) | 103 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | PACIFICSOURCE HEALTH PLANS | 170 | $1.3M |
| Dental | WILLAMETTE DENTAL INSURANCE, INC. | 84 | $49K |
| Vision | LIFEMAP ASSURANCE COMPANY | 103 | $16K |
| Life insurance | UNITED OF OMAHA LIFE INSURANCE COMPANY | 123 | $64K |
| Short-term disability | AFLAC | 9 | $9K |
| Long-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 123 | $64K |
| Prescription drug | PACIFICSOURCE HEALTH PLANS | 170 | $1.3M |
| Other(2 contracts, 2 carriers) | UNITED OF OMAHA LIFE INSURANCE COMPANY | 123 | $73K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 170 | — |
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.