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Employer
4713 Gettysburg Road, Mechanicsburg, PA 17055 · EIN 23-1703931 · 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 $2,989
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | Everest Reinsurance Company | — | 37 | Comp not disclosed Premium $22,266 |
| Dental | Delta Dental Of Pennsylvania | Insurance Colaition Inc. | 26 | $1,594 10.0% of $15,943 |
| Vision | Capital Advantage Assurance Company | — | 84 | Comp not disclosed Premium $4,080 |
| Life | Reliance Standard Life Insurance Company | Pci Insurance Agency | 1 | $185 15.0% of $1,233 |
| Life | Reliance Standard Life Insurance Company | Gis Benefits, Inc. | 1 | $62 5.0% of $1,233 |
| Life | Reliance Standard Life Insurance Company | Pci Insurance Agency | 13 | $30 15.1% of $199 |
| Life | Reliance Standard Life Insurance Company | Gis Benefits, Inc. | 13 | $10 5.0% of $199 |
| AD&D | Reliance Standard Life Insurance Company | Pci Insurance Agency | 3 | $17 15.2% of $112 |
| AD&D | Reliance Standard Life Insurance Company | Gis Benefits, Inc. | 3 | $6 5.4% of $112 |
| Weekly Income | Reliance Standard Life Insurance Company | Pci Insurance Agency | 22 | $385 15.0% of $2,568 |
| Weekly Income | Reliance Standard Life Insurance Company | Gis Benefits | 22 | $128 5.0% of $2,568 |
| Other | Reliance Standard Life Insurance Company | Pci Insurance Agency | 12 | $429 15.0% of $2,860 |
| Other | Reliance Standard Life Insurance Company | Gis Benefits, Inc. | 12 | $143 5.0% of $2,860 |
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 $2,701
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| Pci Insurance Agency | Broker | $1,036 | $12.33 |
| The Benecon Group | Broker | $933 | $11.11 |
| Capital Blue Cross | Admin | $538 | $6.40 |
| Connectcare 3 | Patient Advocate | $194 | $2.31 |