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Employer
2101 W Pike St, Houston, PA 15342 · EIN 46-2793780 · Jan 1, 2024 to Dec 31, 2024
Plan year 2024
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Schedule A
Coverage contracts on the filing. If the carrier did not provide Schedule A, the row is listed with that note.
Visible subtotal $29,644
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | Everest Reinsurance Company | — | — | Comp not disclosed Premium $932 |
| Stop-loss | HM Life Insurance Company | — | 156 | Comp not disclosed Premium $595,929 |
| Dental | United Concordia Insurance Company | The Dbj Group Inc | 283 | $11,730 12.2% of $95,893 |
| Vision | Eyemed Vision Care | The Dbj Group Inc | 272 | $1,532 8.0% of $19,081 |
| Vision | Eyemed Vision Care | First National Insurance Agency | 272 | $-13 -0.1% of $19,081 |
| Life | United Of Omaha Life Insurance Company | The Dbj Group Inc | 214 | $2,964 10.7% of $27,829 |
| Life | United Of Omaha Life Insurance Company | Dmc Benefits Inc | 214 | $1,948 7.0% of $27,829 |
| Other | United Of Omaha Life Insurance Company | The Dbj Group Inc | 214 | $3,679 12.2% of $30,222 |
| Other | United Of Omaha Life Insurance Company | Dmc Benefits Inc | 214 | $2,116 7.0% of $30,222 |
| Other | United Of Omaha Life Insurance Company | The Dbj Group Inc | 213 | $3,326 9.9% of $33,745 |
| Other | United Of Omaha Life Insurance Company | Dmc Benefits Inc | 213 | $2,362 7.0% of $33,745 |
Schedule C
Plan-paid amounts to each named party on the filing, with the role they reported. This is not a carrier commission and is not added to Schedule A.
Visible subtotal $108,308
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| The Djb Group | Broker | $39,960 | $256.15 |
| The Benecon Group | Broker | $30,936 | $198.31 |
| Highmark West | Admin | $26,665 | $170.93 |
| Connectcare 3 | Patient Advocate | $10,747 | $68.89 |