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Employer
2005 Market Street, Suite 1100, Philadelphia, PA 19103 · EIN 98-0607844 · 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 $21,736
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Dental | Humana | Pcf Ins Services Of The West DBA Pe | 105 | $3,345 3.4% of $98,789 |
| Vision | Eyemed Vision Care | Pcf Insurance Services Of The West | 398 | $1,502 10.0% of $14,995 |
| Life | United Of Omaha Life Insurance Company | — | — | Schedule A not provided |
| AD&D | United Of Omaha Life Insurance Company | Pcf Insurance Services Of The West | 63 | $2,195 7.9% of $27,717 |
| AD&D | United Of Omaha Life Insurance Company | Kistler Tiffany Benefits Co | 63 | $1,661 6.0% of $27,717 |
| AD&D | United Of Omaha Life Insurance Company | Onedigital Premier Services LLC | 63 | $1,386 5.0% of $27,717 |
| Other | United Of Omaha Life Insurance Company | Pcf Insurance Services Of The West | 135 | $2,027 7.9% of $25,592 |
| Other | United Of Omaha Life Insurance Company | Kistler Tiffany Benefits Co | 135 | $1,493 5.8% of $25,592 |
| Other | United Of Omaha Life Insurance Company | Onedigital Premier Services LLC | 135 | $1,280 5.0% of $25,592 |
| Other | United Of Omaha Life Insurance Company | Pcf Insurance Services Of The West | 69 | $2,837 7.9% of $35,825 |
| Other | United Of Omaha Life Insurance Company | Kistler Tiffany Benefits Co | 69 | $2,219 6.2% of $35,825 |
| Other | United Of Omaha Life Insurance Company | Onedigital Premier Services LLC | 69 | $1,791 5.0% of $35,825 |
| Stop-loss | Sun Life Assurance Company | — | 121 | Comp not disclosed Premium $500,720 |
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 $104,480
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| Revive Health | Admin | $5,902 | $14.83 |
| Pcf Insurance Services Of The West | Broker | $43,890 | $327.54 |
| The Benecon Group | Broker | $23,247 | $173.49 |
| Independence Administrators | Admin | $23,365 | $174.37 |
| ConnectCare3 | Patient Advocate | $8,076 | $60.27 |