| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| FILICE INSURANCE AGENCY3 | 738 N. FIRST STREET SUITE 202 SAN JOSE, CA 95112 | KAISER PERMANENTE | $15K | — | $15K | 5.44% |
| FILICE INSURANCE AGENCY3 Filed as: RON FILICE ENTERPRISES | 738 N. FIRST STREET SUITE 202 SAN JOSE, CA 95112 | SUN LIFE ASSURANCE CO OF CANADA | $14K | — | $14K | 12.16% |
| ROLANDO VELOZ3 | 607 N. FIRST STREET SAN JOSE, CA 95112 | SUN LIFE ASSURANCE CO OF CANADA | $11 | — | $11 | 0.01% |
| CLIFFORD DERR3 | 5638 COLBOURN PL OAKLAND, CA 94619 | SUN LIFE ASSURANCE CO OF CANADA | $3 | — | $3 | 0.00% |
| FILICE INSURANCE AGENCY3 Filed as: RON FILICE ENTERPRISES | 738 N. FIRST STREET SUITE 202 SAN JOSE, CA 95112 | VISION SERVICE PROVIDER | $1K | — | $1K | 10.00% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| FILICE INSURANCE BROKER | Insurance agents and brokers Service code 22 | 738 N. FIRST STREET SAN JOSE, CA 95112 | $32K |
| BENEFIT RISK AND MANAGEMENT SERVICE EIN 77-0583964 THIRD PARTY ADMINISTRATOR | Claims processing Service code 12 | — | $21K |
| BENEFIT BROKERAGE SERVICE GENERAL AGENT | Insurance agents and brokers Service code 22 | 40485 ENCYCLOPEDIA CIRCLE FREMONT, CA 94538 | $15K |
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 | 127 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 127 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | KAISER PERMANENTE | 59 | $268K |
| Dental | SUN LIFE ASSURANCE CO OF CANADA | 127 | $113K |
| Vision | VISION SERVICE PROVIDER | 89 | $10K |
| Life insurance | SUN LIFE ASSURANCE CO OF CANADA | 127 | $113K |
| Prescription drug | KAISER PERMANENTE | 59 | $268K |
| Stop-loss / reinsurancereinsurance | U.S. FIRE INSURANCE COMPANY | 69 | $254K |
| Other | SUN LIFE ASSURANCE CO OF CANADA | 127 | $113K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 127 | — |
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.