| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| HUB INTERNATIONAL MIDWEST LIMITED3 Filed as: BOLTON INSURANCE SERVICES LLC | P.O. BOX 6030 PASADENA, CA 911026030 | KAISER FOUNDATION HEALTH PLAN INC. | $25K | — | $25K | 4.49% |
| GALLAGHER BENEFIT SERVICES, INC.3 Filed as: GALLAGHER BENEFIT SVCS. OF | P.O. BOX 3009 ARLINGTON HEIGHTS, IL 600063009 | KAISER FOUNDATION HEALTH PLAN INC. | — | $480 | $480 | 0.09% |
| HUB INTERNATIONAL MIDWEST LIMITED3 Filed as: BOLTON & COMPANY | 3475 E. FOOTHILL BLVD. SUITE 100 PASADENA, CA 91107 | AETNA HEALTH, INC. | $21K | — | $21K | 4.90% |
| HUB INTERNATIONAL MIDWEST LIMITED3 Filed as: BOLTON & COMPANY | 3475 E. FOOTHILL BLVD. SUITE 100 PASADENA, CA 91107 | AETNA LIFE INSURANCE CO. | $14K | $2K | $16K | 5.91% |
| BOON CHAPMAN BENEFIT ADMINISTRATORS5 Filed as: BOON-CHAPMAN BENEFIT ADMINISTRATORS | P.O. BOX 9201 AUSTIN, TX 787669201 | METROPOLITAN LIFE INSURANCE COMPANY | $29K | $7K | $36K | 23.00% |
| GIS BENEFITS INC3 Filed as: GIS BENEFITS INC. | 422 WAUPONSEE ST. MORRIS, IL 604502215 | METROPOLITAN LIFE INSURANCE COMPANY | — | $3K | $3K | 1.94% |
| HUB INTERNATIONAL MIDWEST LIMITED3 Filed as: BOLTON & COMPANY | P.O. BOX 6030 PASADENA, CA 911026030 | METROPOLITAN LIFE INSURANCE COMPANY | — | $39 | $39 | 0.02% |
| RICKY SHIH3 | 314 S. 3RD AVE. ARCADIA, CA 91006 | AFLAC | $2K | — | $2K | 9.65% |
| ALICIA MARGARIT ESPINOZA3 | 170 EL DORADO ST. ARCADIA, CA 91006 | AFLAC | $1K | — | $1K | 7.03% |
| HUB INTERNATIONAL MIDWEST LIMITED3 Filed as: BOLTON & COMPANY | 3475 E. FOOTHILL BLVD. SUITE 100 PASADENA, CA 91107 | AFLAC | $1K | — | $1K | 6.72% |
| JULIA MELLO3 | 5501 ONACREST DR. LOS ANGELES, CA 90043 | AFLAC | $799 | — | $799 | 4.53% |
| MICHAEL R. FISHER3 | 50 W. LEMON AVE. SUITE 2 MONROVIA, CA 91016 | AFLAC | $470 | — | $470 | 2.66% |
| JOSEPH HOFFMAN3 | 29110 TEMBUSO LAKE ELSINORE, CA 92530 | AFLAC | $451 | — | $451 | 2.55% |
| ODALYS YOSELI CORDERO3 | 7776 LION ST. RANCHO CUCAMONGA, CA 91730 | AFLAC | $287 | — | $287 | 1.63% |
| MICHAEL R. FISHER3 | 50 W. LEMON AVE. SUITE 2 MONROVIA, CA 91016 | AFLAC | $172 | — | $172 | 0.97% |
| SHANE M OWEN3 Filed as: SHANE CRAIG DAVISON | 3013 LARGE HOP LN. ANTIOCH, TN 37013 | AFLAC | $93 | — | $93 | 0.53% |
| TERRANCE M LUCZAJ3 Filed as: TERRANCE M. LUCZAJ | 435 HARRODS LN. CHARLESTON, SC 29412 | AFLAC | $49 | — | $49 | 0.28% |
| JANICE M ADAMSON3 Filed as: JANICE M. ADAMSON | 405 S. HIBISCUS WAY ANAHEIM, CA 92808 | AFLAC | $5 | — | $5 | 0.03% |
| SETH JAFFE3 Filed as: SETH L. JAFFE | 4127 E. MASSACHUSETTS ST. LONG BEACH, CA 90814 | AFLAC | $5 | — | $5 | 0.03% |
| GIS BENEFITS INC3 Filed as: GIS BENEFITS INC. | 422 WAUPONSEE ST. MORRIS, IL 604502215 | SAFEGUARD HEALTH PLANS, INC., A CALIFORNIA CORPORATION | — | $286 | $286 | 2.14% |
No Schedule C service providers reported on this filing.
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 | 135 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 3 | Continuation coverage (COBRA, retiree health). |
| Total participants (= "Plan participants" tile) | 138 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical)(3 contracts, 3 carriers) | KAISER FOUNDATION HEALTH PLAN INC. | 108 | $1.3M |
| Dental(2 contracts, 2 carriers) | METROPOLITAN LIFE INSURANCE COMPANY | 201 | $170K |
| Vision | METROPOLITAN LIFE INSURANCE COMPANY | 201 | $157K |
| Life insurance | METROPOLITAN LIFE INSURANCE COMPANY | 201 | $157K |
| Short-term disability | AFLAC | 28 | $18K |
| Long-term disability | METROPOLITAN LIFE INSURANCE COMPANY | 201 | $157K |
| Prescription drug(3 contracts, 3 carriers) | KAISER FOUNDATION HEALTH PLAN INC. | 108 | $1.3M |
| Other(2 contracts, 2 carriers) | METROPOLITAN LIFE INSURANCE COMPANY | 201 | $174K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 201 | — |
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.