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Employer
291 N 8th Street, Mifflinburg, PA 17844 · EIN 23-2691903 · 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 $8,407
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | Everest Reinsurance Company | — | — | Comp not disclosed Premium $1,091 |
| Stop-loss | HM Life Insurance Company | — | 59 | Comp not disclosed Premium $386,807 |
| Dental | Delta Dental Of Pennsylvania | Sholley Agency Inc | 99 | $3,448 10.0% of $34,484 |
| Vision | National Vision Administrators, LLC | Sholley Agency Inc | 119 | $407 5.0% of $8,148 |
| Life | United Of Omaha Life Insurance Company | Emerson Rogers LLC | 74 | $1,011 21.4% of $4,714 |
| AD&D | United Of Omaha Life Insurance Company | Emerson Rogers LLC | 33 | $2,847 20.7% of $13,782 |
| Supplemental | Aflac | Barbara A Kennedy | 10 | $141 2.1% of $6,692 |
| Supplemental | Aflac | David M Ryncavage Sr | 10 | $93 1.4% of $6,692 |
| Supplemental | Aflac | Wilson H Transue | 10 | $60 0.9% of $6,692 |
| Supplemental | Aflac | Joseph B Mcginty Jr | 10 | $52 0.8% of $6,692 |
| Supplemental | Aflac | Fred A Reeder | 10 | $48 0.7% of $6,692 |
| Supplemental | Aflac | Kevin D Noll | 10 | $34 0.5% of $6,692 |
| Supplemental | Aflac | Daniel R Judy | 10 | $23 0.3% of $6,692 |
| Supplemental | Aflac | Jeffrey C Chubb | 10 | $15 0.2% of $6,692 |
| Supplemental | Aflac | Harry D Wagner | 10 | $14 0.2% of $6,692 |
| Supplemental | Aflac | Daniel Cero | 10 | $9 0.1% of $6,692 |
| Supplemental | Aflac | Irene E Brooks | 10 | $8 0.1% of $6,692 |
| Supplemental | Aflac | John M Washo | 10 | $8 0.1% of $6,692 |
| Supplemental | Aflac | Charles L Rouser | 10 | $1 0.0% of $6,692 |
| Supplemental | Washington National Insurance Company | Optavise LLC | 14 | $53 0.8% of $6,993 |
| Supplemental | Washington National Insurance Company | Michael Tendler | 14 | $34 0.5% of $6,993 |
| Supplemental | Washington National Insurance Company | Marilyn Olin | 14 | $34 0.5% of $6,993 |
| Supplemental | Washington National Insurance Company | James A Tomko | 14 | $16 0.2% of $6,993 |
| Supplemental | Washington National Insurance Company | Richard S Lee | 14 | $15 0.2% of $6,993 |
| Supplemental | Washington National Insurance Company | Michael A Foster | 14 | $14 0.2% of $6,993 |
| Supplemental | Washington National Insurance Company | Scott A Young | 14 | $10 0.1% of $6,993 |
| Supplemental | Washington National Insurance Company | Nicholas David Barattini | 14 | $7 0.1% of $6,993 |
| Supplemental | Washington National Insurance Company | Emily D Rottscheit | 14 | $5 0.1% of $6,993 |
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 $14,617
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| Sholley Agency, Inc. | Broker | $18,550 | $155.88 |
| The Benecon Group | Broker | $14,789 | $124.28 |
| ConnectCare3 | Patient Advocate | $4,170 | $35.04 |
| Capital Bluecross | Admin | $-22,892 | $-192.37 |