| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| JACK NIXON3 Filed as: JACK G NIXON | 999 5TH AVE SUITE 300 SAN RAFAEL, CA 94901 | CIGNA HEALTH AND LIFE INSURANCE COMPANY | $26K | $0 | $26K | 4.98% |
| JORDAN SHIELDS INSURANCE AGENCY INC3 | 1 WILLOWBROOK COURT SUITE 230 PETALUMA, CA 94954 | CIGNA HEALTH AND LIFE INSURANCE COMPANY | $13K | $0 | $13K | 2.45% |
| JACK NIXON3 | 999 5TH AVE SUITE 300 SAN RAFAEL, CA 94901 | KAISER FOUNDATION HEALTH PLAN INC | $9K | $0 | $9K | 1.68% |
| JORDAN SHIELDS INSURANCE AGENCY INC3 Filed as: JORDAN SHIELDS INSURANCE AGENCY | 1 WILLOWBROOK COURT SUITE 230 PETALUMA, CA 94954 | KAISER FOUNDATION HEALTH PLAN INC | $4K | $0 | $4K | 0.83% |
| JACK NIXON3 | 999 5TH AVE SUITE 300 SAN RAFAEL, CA 94901 | KAISER FOUNDATION HEALTH PLAN INC | $4K | $0 | $4K | 1.68% |
| JORDAN SHIELDS INSURANCE AGENCY INC3 Filed as: JORDAN SHIELDS INSURANCE AGENCY | 1 WILLOWBROOK COURT SUITE 230 PETALUMA, CA 94954 | KAISER FOUNDATION HEALTH PLAN INC | $2K | $0 | $2K | 0.83% |
| JACK NIXON3 Filed as: JACK G NIXON | 999 5TH AVE SUITE 300 SAN RAFAEL, CA 94901 | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | $6K | $0 | $6K | 20.00% |
| JACK NIXON3 Filed as: JACK G NIXON | 999 5TH AVE SUITE 300 SAN RAFAEL, CA 94901 | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | $2K | $0 | $2K | 20.00% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| CIGNA LIFE AND HEATH CO. EIN 59-1031071 CONTRACT ADMINISTRATOR | Float revenue; Claims processing; Participant communication; Other services; Named fiduciary; Non-monetary compensation; Direct payment from the plan; Contract Administrator Service code 12 | 1340 TREAT BLVD. SUITE 599 WALNUT CREEK, CA 94597 | $234K |
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 | 235 | 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. |
| Beneficiaries receiving benefits | 0 | Spouses or dependents with eligibility independent of the participant. |
| Total participants (= "Plan participants" tile) | 235 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(3 contracts, 2 carriers) | CIGNA HEALTH AND LIFE INSURANCE COMPANY | 101 | $1.3M |
| Life insurance | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | 175 | $11K |
| Long-term disability | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | 176 | $32K |
| Other | THE LINCOLN NATIONAL LIFE INSURANCE COMPANY | 175 | $11K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 176 | — |
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 compensation exceeds 5% of premium. Either a small-plan minimum-fee dynamic or an inefficient broker structure ripe for a counter-bid.
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.