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Employer
1648 Letterkenny Road, Chambersburg, PA 17201 · EIN 25-1812439 · Sep 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 $10,200
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | HM Life Insurance Company | — | 53 | Comp not disclosed Premium $218,849 |
| Dental + Vision | Capital Advantage Assurance Company | Assured Partners (Central Pa) | 116 | $3,605 10.0% of $35,988 |
| Life | Metropolitan Life Insurance Company | — | — | Schedule A not provided |
| Life | Metropolitan Life Insurance Company | — | — | Schedule A not provided |
| Life | Metropolitan Life Insurance Company | — | — | Schedule A not provided |
| Life | Metropolitan Life Insurance Company | — | — | Schedule A not provided |
| Voluntary Critical Illness | Reliance Standard Life Insurance Company | Assured Partners | 17 | $435 20.0% of $2,174 |
| Voluntary Critical Illness | Reliance Standard Life Insurance Company | Gis Benefits, Inc. | 17 | $109 5.0% of $2,174 |
| Voluntary Critical Illness | Reliance Standard Life Insurance Company | Emerson Rogers LLC | 17 | $33 1.5% of $2,174 |
| Voluntary Critical Illness | Reliance Standard Life Insurance Company | Gis | 17 | $16 0.7% of $2,174 |
| Voluntary Critical Illness | Reliance Standard Life Insurance Company | Administrators, Inc, Boon-Chapman B | 17 | $11 0.5% of $2,174 |
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 $38,454
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| Assured Partners (Central Pa) | Broker | $19,980 | $172.24 |
| The Benecon Group | Broker | $17,587 | $151.61 |
| Capital Bluecross | Admin. | $887 | $7.65 |