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Employer
639 Chestnut St., Ashland, PA 17921 · EIN 82-2804074 · 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 $39,062
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | HM Life Insurance Company | — | — | Comp not disclosed Premium $84,219 |
| Medical | Highmark, Inc. | Diamant Yitzchok | 73 | $17,016 2.9% of $579,466 |
| Medical | Highmark, Inc. | Emerson Rogers LLC | 73 | $8,508 1.5% of $579,466 |
| Dental | United Concordia Life And Health Insurance Company | — | — | Schedule A not provided |
| Vision | National Vision Administrator, LLC | — | — | Schedule A not provided |
| Life | The Guardian Life Insurance Company | — | — | Schedule A not provided |
| Accident | American Heritage Life Insurance Company | Hipps Crystal | 14 | $621 11.3% of $5,503 |
| Accident | American Heritage Life Insurance Company | Element Risk Management | 14 | $341 6.2% of $5,503 |
| Accident | American Heritage Life Insurance Company | Trocki George | 14 | $93 1.7% of $5,503 |
| Accident | American Heritage Life Insurance Company | Shanaman Amy Jo | 14 | $58 1.1% of $5,503 |
| Accident | American Heritage Life Insurance Company | Day Aubrey L | 14 | $43 0.8% of $5,503 |
| Accident | American Heritage Life Insurance Company | Peterson Douglas C | 14 | $36 0.7% of $5,503 |
| Accident | American Heritage Life Insurance Company | Kulikauskas Jane | 14 | $3 0.1% of $5,503 |
| Cancer | American Heritage Life Insurance Company | Hipps Crystal | 8 | $388 11.2% of $3,460 |
| Cancer | American Heritage Life Insurance Company | Element Risk Management LLC | 8 | $153 4.4% of $3,460 |
| Cancer | American Heritage Life Insurance Company | Trocki George | 8 | $66 1.9% of $3,460 |
| Cancer | American Heritage Life Insurance Company | Shanaman Amy Jo | 8 | $26 0.8% of $3,460 |
| Cancer | American Heritage Life Insurance Company | Day Aubrey L | 8 | $24 0.7% of $3,460 |
| Cancer | American Heritage Life Insurance Company | Peterson Douglas C | 8 | $15 0.4% of $3,460 |
| Disability | American Heritage Life Insurance Company | Hipps Crystal | 17 | $2,681 10.3% of $25,941 |
| Disability | American Heritage Life Insurance Company | Element Risk Management LLC | 17 | $1,544 6.0% of $25,941 |
| Disability | American Heritage Life Insurance Company | Trocki George A | 17 | $701 2.7% of $25,941 |
| Disability | American Heritage Life Insurance Company | Peterson Douglas C | 17 | $226 0.9% of $25,941 |
| Disability | American Heritage Life Insurance Company | Shanaman Amy Jo | 17 | $196 0.8% of $25,941 |
| Disability | American Heritage Life Insurance Company | Day Aubrey L | 17 | $121 0.5% of $25,941 |
| Disability | American Heritage Life Insurance Company | Gelhard Donna | 17 | $37 0.1% of $25,941 |
| Disability | American Heritage Life Insurance Company | Kulikauskas Jane | 17 | $21 0.1% of $25,941 |
| Disability | American Heritage Life Insurance Company | Bristol Robert | 17 | $15 0.1% of $25,941 |
| Disability | American Heritage Life Insurance Company | Roller David | 17 | $9 0.0% of $25,941 |
| Traditional Life | American Heritage Life Insurance Company | Hipps Crystal | 4 | $607 17.4% of $3,479 |
| Traditional Life | American Heritage Life Insurance Company | Element Risk Management LLC | 4 | $306 8.8% of $3,479 |
| Traditional Life | American Heritage Life Insurance Company | Day Aubrey L | 4 | $91 2.6% of $3,479 |
| Traditional Life | American Heritage Life Insurance Company | Peterson Douglas C | 4 | $51 1.5% of $3,479 |
| Traditional Life | American Heritage Life Insurance Company | Trocki George | 4 | $18 0.5% of $3,479 |
| Traditional Life | American Heritage Life Insurance Company | Kulikauskas Jane | 4 | $2 0.1% of $3,479 |
| Accident | American Heritage Life Insurance Company | Hipps Crystal | — | $5 5.4% of $92 |
| Accident | American Heritage Life Insurance Company | Element Risk Management LLC | — | $2 2.2% of $92 |
| Accident | American Heritage Life Insurance Company | Kulkauskas Jane | — | $1 1.1% of $92 |
| Accident | American Heritage Life Insurance Company | Peterson Douglas C | — | $1 1.1% of $92 |
| Cancer | American Heritage Life Insurance Company | Hipps Crystal | 4 | $154 9.3% of $1,650 |
| Cancer | American Heritage Life Insurance Company | Element Risk Management LLC | 4 | $125 7.6% of $1,650 |
| Cancer | American Heritage Life Insurance Company | Trocki George | 4 | $33 2.0% of $1,650 |
| Cancer | American Heritage Life Insurance Company | Peterson Douglas C | 4 | $16 1.0% of $1,650 |
| Cancer | American Heritage Life Insurance Company | Bristol Robert | 4 | $9 0.5% of $1,650 |
| Cancer | American Heritage Life Insurance Company | Kalikauska Jane | 4 | $3 0.2% of $1,650 |
| Accident | American Heritage Life Insurance Company | Hipps Crystal | 2 | $273 19.0% of $1,434 |
| Accident | American Heritage Life Insurance Company | Element Risk Management LLC | 2 | $133 9.3% of $1,434 |
| Accident | American Heritage Life Insurance Company | Trocki George | 2 | $16 1.1% of $1,434 |
| Accident | American Heritage Life Insurance Company | Peterson Douglas C | 2 | $16 1.1% of $1,434 |
| Accident | American Heritage Life Insurance Company | Shanaman Amy Jo | 2 | $15 1.0% of $1,434 |
| Accident | American Heritage Life Insurance Company | Kulikauskas Jane | 2 | $5 0.3% of $1,434 |
| Accident | American Heritage Life Insurance Company | Roller David | 2 | $3 0.2% of $1,434 |
| Cancer | American Heritage Life Insurance Company | Hipps Crystal | — | $3 4.9% of $61 |
| Cancer | American Heritage Life Insurance Company | Element Risk Management LLC | — | $2 3.3% of $61 |
| Cancer | American Heritage Life Insurance Company | Kulikauskas Jane | — | $1 1.6% of $61 |
| Disability | American Heritage Life Insurance Company | Hipps Crystal | 4 | $823 18.5% of $4,448 |
| Disability | American Heritage Life Insurance Company | Element Risk Management LLC | 4 | $400 9.0% of $4,448 |
| Disability | American Heritage Life Insurance Company | Peterson Douglas C | 4 | $72 1.6% of $4,448 |
| Disability | American Heritage Life Insurance Company | Trocki George | 4 | $66 1.5% of $4,448 |
| Disability | American Heritage Life Insurance Company | Shanaman Jo | 4 | $47 1.1% of $4,448 |
| Disability | American Heritage Life Insurance Company | Kulikauska Jane | 4 | $11 0.2% of $4,448 |
| Traditional Life | American Heritage Life Insurance Company | Hipps Crystal | 1 | $197 54.7% of $360 |
| Traditional Life | American Heritage Life Insurance Company | Element Risk Management LLC | 1 | $85 23.6% of $360 |
| Traditional Life | American Heritage Life Insurance Company | Peterson Douglas C | 1 | $12 3.3% of $360 |
| Universal Life | American Heritage Life Insurance Company | Hipps Crystal | 1 | $26 2.7% of $960 |
| Universal Life | American Heritage Life Insurance Company | Shanaman Amy Jo | 1 | $21 2.2% of $960 |
| Universal Life | American Heritage Life Insurance Company | Element Risk Management LLC | 1 | $20 2.1% of $960 |
| Universal Life | American Heritage Life Insurance Company | Trocki George | 1 | $12 1.3% of $960 |
| Disability | American Heritage Life Insurance Company | Hipps Crystal | — | $1,604 28.3% of $5,669 |
| Disability | American Heritage Life Insurance Company | Element Risk Management LLC | — | $687 12.1% of $5,669 |
| Disability | American Heritage Life Insurance Company | Peterson Douglas C | — | $146 2.6% of $5,669 |
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 $4,344
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| The Benecon Group, LLC | Broker | $2,924 | $40.05 |
| Pci (Pa Chamber Insurance) | Broker | $1,444 | $19.78 |
| Capital Blue Cross | Admin | $-24 | $-0.33 |