No insurance carriers on this filing. Self-funded welfare plans typically pay TPAs and PBMs through Schedule C, not Schedule A.
No brokers reported on this filing.
| Provider | Services | Address | Compensation |
|---|---|---|---|
| SIU PD SUPP BENEFITS FUND, INC. EIN 94-1431246 COMMON TRUSTEES | Direct payment from the plan; Contract Administrator Service code 13 | — | $147K |
| RUSLANA BOYCHUK EIN 94-2430964 EMPLOYEE | Employee (plan); Direct payment from the plan Service code 30 | — | $128K |
| OCCUPATIONAL HEALTH CENTERS OF - CO EIN 77-0469725 NONE | Direct payment from the plan; Other services Service code 49 | — | $107K |
| NORMA AMBRIZ EIN 94-2430964 EMPLOYEE | Employee (plan); Direct payment from the plan Service code 30 | — | $92K |
| MEDISON CORPORATION NONE | Direct payment from the plan; Other services Service code 49 | 2551 W WOODLAND DR ANAHEIM, CA 92801 | $45K |
| MERCY DOCTORS MEDICAL GROUP EIN 94-3156511 NONE | Direct payment from the plan; Other services Service code 49 | — | $45K |
| URGENT CARE CLINIC OF WAIKIKI EIN 99-0629293 NONE | Direct payment from the plan; Other services Service code 49 | — | $37K |
| KAISER FOUNDATION HEALTH PLAN OF WA EIN 91-0511770 NONE | Direct payment from the plan; Other services Service code 49 | — | $32K |
| WITHUMSMITH+BROWN, PC EIN 22-2027092 NONE | Direct payment from the plan; Accounting (including auditing) Service code 10 | — | $28K |
| MEDTOX LABS EIN 52-1130579 NONE | Other services; Direct payment from the plan Service code 49 | — | $19K |
| DR. CARL BRICCA, DO NONE | Other services; Direct payment from the plan Service code 49 | 1 SHRADER ST #640 SAN FRANCISCO, CA 94117 | $18K |
| STEPHEN HORN INSURANCE EIN 94-3249244 NONE | Direct payment from the plan; Insurance services Service code 23 | — | $6K |
| US BANK EIN 31-0841368 NONE | Direct payment from the plan; Other services Service code 49 | — | $6K |
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 | 401 | 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) | 401 | Active + retired/separated + beneficiaries. No dependents. |
No Schedule A insurance contracts on this filing — typical of fully self-funded plans, where the only headcount is the Form 5500 number above.
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."
No prospect flags tripped on this filing.