| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| USI INSURANCE SERVICES LLC3 Filed as: USI NORTHWEST | 700 NE MULTNOMAH, SUITE 1300 PORTLAND, OR 97232 | PACIFICSOURCE HEALTH PLANS | $37K | — | $37K | 2.81% |
| USI INSURANCE SERVICES LLC3 Filed as: KIBBLE AND PRENTICE HOLDING COMPANY | 601 UNION STREET, SUITE 1000 SEATTLE, WA 98101 | HARTFORD LIFE AND ACCIDENT | $8K | — | $8K | 16.43% |
| USI INSURANCE SERVICES LLC3 Filed as: USI INSURANCE SERVICES, LLC | 470 PARK AVENUE SOUTH, 6TH FLOOR NEW YORK, NY 10016 | HARTFORD LIFE AND ACCIDENT | — | $830 | $830 | 1.76% |
| CAROL A. KENYON3 | 1641 CLEVELAND HILL ROAD ROSEBURG, OR 97471 | CONTINENTAL AMERICAN INSURANCE COMPANY | $1K | — | $1K | 5.03% |
| MARCI MARIE OTIS3 Filed as: MARCI M. OTIS | 200 JULINA LANE ROSEBURG, OR 97471 | CONTINENTAL AMERICAN INSURANCE COMPANY | $1K | — | $1K | 4.26% |
| SHAWN M. OTIS3 | 200 JULINA LANE ROSEBURG, OR 97471 | CONTINENTAL AMERICAN INSURANCE COMPANY | $219 | — | $219 | 0.79% |
| MARK D LUTHER3 Filed as: MARK D. LUTHER | 804 MOOREFIELD PARK DRIVE SUITE 106 RICHMOND, VA 23236 | CONTINENTAL AMERICAN INSURANCE COMPANY | $218 | — | $218 | 0.79% |
| RAYMON P KEECH III3 Filed as: RAYMON P. KEECH III | 8207 CAMPAIGN CIRCLE RICHMOND, TX 77406 | CONTINENTAL AMERICAN INSURANCE COMPANY | $155 | — | $155 | 0.56% |
| MJ INSURANCE3 Filed as: KIMBERLY A PARKS AND VARIOUS AGENTS | 19818 NORTH 147 AVENUE SUN CITY WEST, AZ 85375 | CONTINENTAL AMERICAN INSURANCE COMPANY | $111 | — | $111 | 0.40% |
| MATTHEW S SHROYER3 Filed as: MATTHEW S. SHROYER | 7407 NORTH WILLIAMS AVENUE PORTLAND, OR 97217 | CONTINENTAL AMERICAN INSURANCE COMPANY | $21 | — | $21 | 0.08% |
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 | 168 | 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) | 168 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | PACIFICSOURCE HEALTH PLANS | 293 | $1.3M |
| Dental | PACIFICSOURCE HEALTH PLANS | 293 | $1.3M |
| Vision | PACIFICSOURCE HEALTH PLANS | 293 | $1.3M |
| Life insurance | HARTFORD LIFE AND ACCIDENT | 32 | $47K |
| Short-term disability | HARTFORD LIFE AND ACCIDENT | 32 | $47K |
| Long-term disability | HARTFORD LIFE AND ACCIDENT | 32 | $47K |
| Prescription drug | PACIFICSOURCE HEALTH PLANS | 293 | $1.3M |
| Other(3 contracts, 3 carriers) | HARTFORD LIFE AND ACCIDENT | 167 | $80K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 293 | — |
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.