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Employer
2801 Custer Avenue, Suite G, Pittsburgh, PA 15227 · EIN 25-1685793 · Jul 1, 2024 to Jun 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 $85,626
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Medical | Upmc Health Options | Liberty Insurance Services | 6 | $574 1.6% of $36,029 |
| Medical | Upmc Health Options | Liberty Insurance Services | 7 | $376 2.3% of $16,505 |
| Medical | Upmc Health Options | Liberty Insurance Services | 5 | $1,069 2.0% of $52,175 |
| Medical | Upmc Health Options | Liberty Insurance Services | 34 | $4,088 1.5% of $273,740 |
| Medical | Upmc Health Options | Liberty Insurance Services | 35 | $4,990 1.6% of $305,932 |
| Medical | Upmc Health Options | Liberty Insurance Services | 77 | $8,492 1.5% of $571,442 |
| Medical | Upmc Health Options | Daniel Destefano | 1 | $133 1.6% of $8,103 |
| Medical | Upmc Health Options | Liberty Insurance Services | 1 | $133 1.6% of $8,103 |
| Medical | Upmc Health Options | Liberty Insurance Services | — | $93 2.9% of $3,208 |
| Medical | Upmc Health Options | Liberty Insurance Services | 4 | $252 1.3% of $19,333 |
| Medical | Upmc Health Options | Liberty Insurance Services | 14 | $1,022 1.2% of $83,628 |
| Medical | Upmc Health Options | Liberty Insurance Services | 12 | $1,275 1.4% of $91,743 |
| Medical | Upmc Health Options | Liberty Insurance Services | 25 | $3,388 1.7% of $204,276 |
| Medical | Upmc Health Options | Liberty Insurance Services | 43 | $4,536 1.5% of $294,557 |
| Medical | Upmc Health Options | Liberty Insurance Services | 42 | $3,678 1.6% of $236,937 |
| Medical | Upmc Health Options | Liberty Insurance Services | 29 | $2,464 1.6% of $152,883 |
| Medical | Upmc Health Options | Liberty Insurance Services | 51 | $4,891 1.5% of $320,810 |
| Medical | Upmc Health Options | Liberty Insurance Services | 25 | $1,789 1.3% of $139,619 |
| Medical | Upmc Health Options | Liberty Insurance Services | 35 | $1,750 1.1% of $157,050 |
| Medical | Upmc Health Options | Liberty Insurance Services | — | $26 2.0% of $1,289 |
| Dental + Vision | Upmc Health Benefits | Liberty Insurance Services | 162 | $4,106 9.6% of $42,690 |
| Dental + Vision | Upmc Health Benefits | Liberty Insurance Services | 1 | $36 9.4% of $384 |
| Dental + Vision | Upmc Health Benefits | Liberty Insurance Services | 193 | $4,986 9.7% of $51,472 |
| Dental + Vision | Upmc Health Benefits | Liberty Insurance Services | 1 | $30 7.8% of $384 |
| Dental + Vision | Upmc Health Benefits | Liberty Insurance Services | 269 | $7,543 9.3% of $80,830 |
| Dental + Vision | Upmc Health Benefits | Liberty Insurance Services | — | $61 10.8% of $567 |
| Dental + Vision | Upmc Health Benefits | Liberty Insurance Services | 108 | $2,054 8.4% of $24,484 |
| Dental + Vision | Upmc Health Benefits | Liberty Insurance Services | 8 | $151 7.7% of $1,959 |
| Dental + Vision | Upmc Health Benefits | Liberty Insurance Services | 7 | $187 10.4% of $1,795 |
| Dental + Vision | Upmc Health Benefits | Liberty Insurance Services | 11 | $255 9.2% of $2,773 |
| Dental + Vision | Upmc Health Benefits | Liberty Insurance Services | 14 | $219 9.9% of $2,217 |
| Life | Sun Life Assurance Company Of Canada | Daniel Destefano | 415 | $14,137 10.3% of $137,269 |
| Life | Sun Life Assurance Company Of Canada | Dmc Benefits Inc | 415 | $6,842 5.0% of $137,269 |
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 $46,933
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| First National Trust Company | None | $19,764 | $41.87 |
| Sun Life Assurance Co. Of Canada | None | $14,669 | $31.08 |
| Baker Tilly | None | $12,500 | $26.48 |