| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| USI INSURANCE SERVICES LLC3 Filed as: USI INSURANCE SERVICES NORTHWEST | 825 NE MULTNOMAH STREET, SUITE 1500 PORTLAND, OR 97232 | PACIFICSOURCE HEALTH PLANS | $46K | $0 | $46K | 2.65% |
| USI INSURANCE SERVICES LLC3 | PO BOX 62683 VIRGINIA BEACH, VA 23466 | HARTFORD LIFE AND ACCIDENT | $10K | $0 | $10K | 16.45% |
| USI INSURANCE SERVICES LLC3 | 470 PARK AVENUE SOUTH, 6TH FLOOR NEW YORK, NY 10016 | HARTFORD LIFE AND ACCIDENT | $0 | $602 | $602 | 1.00% |
| USI INSURANCE SERVICES LLC3 Filed as: USI INSURANCE SERVICES NORTHWEST | 825 NE MULTNOMAH STREET, SUITE 1500 PORTLAND, OR 97232 | WILLAMETTE DENTAL INSURANCE, INC. | $3K | $0 | $3K | 8.00% |
| MARCI MARIE OTIS3 Filed as: MARCI M. OTIS | 200 JULINA LANE ROSEBURG, OR 97471 | CONTINENTAL AMERICAN INSURANCE COMPANY | $3K | $0 | $3K | 8.95% |
| CAROL A. KENYON3 | 1641 CLEVELAND HILL ROAD ROSEBURG, OR 97471 | CONTINENTAL AMERICAN INSURANCE COMPANY | $3K | $0 | $3K | 7.60% |
| JEROMY E. CILLEY3 | 1115 PERAL STREET EUGENE, OR 97401 | CONTINENTAL AMERICAN INSURANCE COMPANY | $470 | $0 | $470 | 1.39% |
| RAYMON P KEECH III3 Filed as: RAYMON P KEECH III AND OTHER AGENTS | 8207 CAMPAIGN CIRCLE RICHMOND, TX 77406 | CONTINENTAL AMERICAN INSURANCE COMPANY | $179 | $0 | $179 | 0.53% |
| SHAWN M. OTIS3 | 200 JULINA LANE ROSEBURG, OR 97471 | CONTINENTAL AMERICAN INSURANCE COMPANY | $178 | $0 | $178 | 0.53% |
| MARK D LUTHER3 Filed as: MARK D. LUTHER | 804 MOOREFIELD PARK DRIVE SUITE 106 RICHMOND, VA 23236 | CONTINENTAL AMERICAN INSURANCE COMPANY | $178 | $0 | $178 | 0.53% |
| TYLER M. OTIS3 | 200 JULINA LANE ROSEBURG, OR 97471 | CONTINENTAL AMERICAN INSURANCE COMPANY | $178 | $0 | $178 | 0.53% |
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 | 228 | 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) | 228 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | PACIFICSOURCE HEALTH PLANS | 369 | $1.7M |
| Dental(2 contracts, 2 carriers) | PACIFICSOURCE HEALTH PLANS | 369 | $1.8M |
| Vision | PACIFICSOURCE HEALTH PLANS | 369 | $1.7M |
| Life insurance | HARTFORD LIFE AND ACCIDENT | 228 | $60K |
| Short-term disability | HARTFORD LIFE AND ACCIDENT | 228 | $60K |
| Long-term disability | HARTFORD LIFE AND ACCIDENT | 228 | $60K |
| Prescription drug | PACIFICSOURCE HEALTH PLANS | 369 | $1.7M |
| Other(3 contracts, 3 carriers) | HARTFORD LIFE AND ACCIDENT | 228 | $134K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 369 | — |
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.