| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| FILICE INSURANCE AGENCY3 | 738 N. FIRST STREET, SUITE 202 SAN JOSE, CA 95112 | BLUE SHIELD OF CALIFORNIA | — | $255 | $255 | 0.06% |
| AXA ASSISTANCE, USA5 | 122 SOUTH MICHIGAN AVENUE, SUITE 11 CHICAGO, IL 606036115 | PRUDENTIAL INSURANCE COMPANY OF AMERICA | — | $63 | $63 | 0.04% |
| AGIS NETWORK INC3 Filed as: AGIS NETWORK, INC. | 2122 KRATKY ROAD ST. LEWIS, MO 63114 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $10K | $851 | $11K | 18.69% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| UNION SECURITY INSURANCE COMPANY EIN 81-0170040 CONTRACT ADMINISTRATOR | Claims processing; Other fees Service code 12 | — | $12K |
| COMPSYCH EIN 35-3739783 THIRD PARTY ADMIN | Contract Administrator Service code 13 | — | $1K |
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 | 343 | 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) | 343 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(2 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN, INC. | 343 | $2.3M |
| Vision | VISION SERVICE PLAN | 86 | $10K |
| Life insurance | PRUDENTIAL INSURANCE COMPANY OF AMERICA | 189 | $141K |
| Long-term disability | PRUDENTIAL INSURANCE COMPANY OF AMERICA | 189 | $141K |
| Prescription drug(2 contracts, 2 carriers) | KAISER FOUNDATION HEALTH PLAN, INC. | 343 | $2.3M |
| Other(2 contracts, 2 carriers) | PRUDENTIAL INSURANCE COMPANY OF AMERICA | 189 | $198K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 343 | — |
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."
Broker comp is under 1% of premium on a >$1M plan. Plan may be flying solo or paying a flat fee — consultant sales target.
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.