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Employer
20 East Sixth Street, Waynesboro, PA 17268 · EIN 25-1373199 · Oct 1, 2024 to Sep 30, 2025
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 $29,166
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | Nationwide Life Insurance Company | — | — | Schedule A not provided |
| Dental | Standard Insurance Company | Brown & Brown Of Pennsylvania | 214 | $6,503 10.0% of $64,996 |
| Dental | Standard Insurance Company | Brown & Brown Of Ny Inc | 214 | $850 1.3% of $64,996 |
| Vision | Standard Insurance Company | Brown & Brown Of Pennsylvania | 213 | $1,737 10.0% of $17,368 |
| Vision | Standard Insurance Company | Brown & Brown Of Ny | 213 | $228 1.3% of $17,368 |
| Life | Standard Insurance Company | Brown & Brown Of Pennsylvania | 209 | $4,839 15.0% of $32,315 |
| Life | Standard Insurance Company | Brown & Brown Of Ny | 209 | $871 2.7% of $32,315 |
| Other | Standard Insurance Company | Brown & Brown Of Pennsylvania | 209 | $12,026 15.0% of $80,171 |
| Other | Standard Insurance Company | Brown & Brown Of Ny | 209 | $2,112 2.6% of $80,171 |
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 $-15,785
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| Capital Advantage Assurance Company | Admin | $-15,785 | $-68.33 |