| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| STOP LOSS INSURANCE SERVICES, INC.3 | 940 ADAMS STREET SUITE G BENICIA, CA 94510 | THE UNION LABOR LIFE INSURANCE COMPANY | $40K | — | $40K | 5.00% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| MASONRY INDUSTRY TRUST ADMIN. EIN 93-1144705 | Claims processing; Recordkeeping and information management (computing, tabulating, data processing, etc.); Recordkeeping fees; Direct payment from the plan; Contract Administrator Service code 12 | — | $303K |
| UNITED CLAIM SOLUTIONS | Consulting (general); Direct payment from the plan; Consulting fees Service code 16 | 23048 N 15TH AVENUE PHOENIX, AZ 85027 | $278K |
| MIDDLETON & CO, CPA, PC EIN 93-0809066 | Direct payment from the plan; Accounting (including auditing) Service code 10 | — | $144K |
| BRADLEY L. MIDDLETON, PC EIN 93-1215960 | Legal; Direct payment from the plan Service code 29 | — | $104K |
| INNOVATIVE CARE MANAGEMENT | Recordkeeping and information management (computing, tabulating, data processing, etc.); Direct payment from the plan Service code 15 | PO BOX 22386 PORTLAND, OR 97269 | $52K |
| MODA HEALTH PLAN, INC. EIN 93-0989307 | Direct payment from the plan; Claims processing Service code 12 | 601 SW SECOND AVENUE PORTLAND, OR 97204 | $41K |
| PROSERVE HEALTH INFORMATICS | Consulting (general); Direct payment from the plan Service code 16 | PO BOX 968 CUYAHOGA FALLS, OH 44223 | $21K |
| MILLIMAN EIN 91-0675641 | Direct payment from the plan; Consulting fees; Actuarial Service code 11 | 111 SW FIFTH AVENUE STE 3700 PORTLAND, OR 972043654 | $20K |
| KEYCORP EIN 34-6542451 | Shareholder servicing fees; Contract Administrator; Recordkeeping fees; Account maintenance fees; Direct payment from the plan; Custodial (other than securities); Custodial (securities); Recordkeeping and information management (computing, tabulating, data processing, etc.) Service code 13 | — | $6K |
| ECHO HEALTH, INC. | Consulting (general); Copying and duplicating; Direct payment from the plan Service code 16 | 868 CORPORATE WAY WESTLAKE, OH 44145 | $6K |
| MET WEST 95-4625304 | Other investment fees and expenses; Distribution (12b-1) fees; Investment management fees paid indirectly by plan Service code 52 | — | $5K |
| DODGE & COX 94-3073289 | Distribution (12b-1) fees; Other investment fees and expenses; Investment management fees paid indirectly by plan Service code 52 | — | $5K |
| KEYCORP 34-6542451 | Custodial (securities); Recordkeeping fees; Shareholder servicing fees; Custodial (other than securities); Contract Administrator; Account maintenance fees; Recordkeeping and information management (computing, tabulating, data processing, etc.); Direct payment from the plan Service code 13 | — | $84 |
| DODGE & COX EIN 94-3073289 | Other investment fees and expenses; Distribution (12b-1) fees; Investment management fees paid indirectly by plan Service code 52 | — | $0 |
| MET WEST EIN 95-4625304 | Other investment fees and expenses; Investment management fees paid indirectly by plan; Distribution (12b-1) fees Service code 52 | — | $0 |
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 | 503 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 203 | Continuation coverage (COBRA, retiree health). |
| Total participants (= "Plan participants" tile) | 0 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST | 129 | $461K |
| Dental(3 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST | 129 | $484K |
| Vision(2 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST | 654 | $519K |
| Life insurance | SYMETRA LIFE INSURANCE COMPANY | 480 | $6K |
| Prescription drug | KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST | 129 | $461K |
| Stop-loss / reinsurancereinsurance | THE UNION LABOR LIFE INSURANCE COMPANY | 652 | $793K |
| Other | SYMETRA LIFE INSURANCE COMPANY | 480 | $6K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 654 | — |
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."
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.