Employer
Country Cupboard Inn
115 Farley Circle, Lewisburg, PA 17837 · EIN 23-2361693 · Jan 1, 2024 to Dec 31, 2024
Plan year 2024
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Schedule A
Direct compensation
Coverage contracts on the filing. If the carrier did not provide Schedule A, the row is listed with that note.
Visible subtotal $876
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | Everest Reinsurance Company | — | — | Comp not disclosed Premium $572 |
| Stop-loss | Optum Health (Unimerica Insurance Company) | — | 27 | Comp not disclosed Premium $100,456 |
| Dental | Delta Dental Of Pennsylvania | Brown & Brown Of Pennsylvania | 56 | $747 5.0% of $14,935 |
| Vision | Vision Benefits Of America | Brown & Brown Of Pennsylvania | 27 | $129 5.0% of $2,570 |
Schedule C
Additional compensation
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 $36,201
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| Brown & Brown (Pa) | Broker | $10,950 | $195.54 |
| The Benecon Group, LLC | Broker | $9,789 | $174.80 |
| Geisinger Health Plan | Admin | $13,208 | $235.86 |
| Connectcare 3 | Other | $2,266 | $40.46 |
| Innovu | Other | $-12 | $-0.21 |