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Employer
Po Box D, Bally, PA 19503 · EIN 23-0382360 · Jan 1, 2022 to Dec 31, 2022
Plan year 2022
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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 $119,344
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Life | Unum Life Insurance Company Of America | Cbiz Benefits & Ins. Services | 226 | $938 2.3% of $41,418 |
| Life | Unum Life Insurance Company Of America | Cbiz Benefits & Ins. Services | 226 | $821 2.0% of $41,418 |
| Life | The Lincoln National Life Insurance Company | Cbiz Benefits & Ins. Services | 241 | $819 5.3% of $15,408 |
| Other | The Lincoln National Life Insurance Company | Cbiz Benefits & Ins. Services | 241 | $1,327 1.9% of $70,440 |
| Stop-loss | HM Life Insurance Company | Cbiz Benefits & Ins. Services | 193 | Comp not disclosed Premium $308,525 |
| Medical | Starmount Life Insurance Company | Cbiz Benefits & Ins. Services | 104 | $1,525 2.0% of $75,902 |
| Medical | Starmount Life Insurance Company | Cbiz Benefits & Ins. Services | 104 | $7,626 10.0% of $75,902 |
| Medical | Aetna Life Insurance Company | Cbiz Benefits & Ins. Services | 23 | $898 8.5% of $10,598 |
| Vision | Capital Advantage Assurance Company | Cbiz Benefits & Ins. Services | 322 | $105,390 1084.1% of $9,721 |
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 $131,447
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| Capital Advantage Assurance Company | Recordkeeper | $123,779 | $384.41 |
| Rx Benefits, Inc | Recordkeeper | $7,668 | $23.81 |