Employer
Lisi Oil Co.
137 E Broad St, Elizabethville, PA 17023 · EIN 23-1989650 · Dec 1, 2021 to Dec 31, 2021
Plan year 2021
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Schedule A
Direct compensation
Coverage contracts on the filing. If the carrier did not provide Schedule A, the row is listed with that note.
Visible subtotal $3
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | Everest Reinsurance Company | — | 15 | Comp not disclosed Premium $5,791 |
| Vision | Capital Advantage Assurance Company | Insurance Coalition | 21 | $3 4.4% of $68 |
Schedule C
Additional compensation
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 $1,245
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| Pci Insurance Agency | Broker | $420 | $20.00 |
| The Benecon Group, LLC | Broker | $275 | $13.10 |
| Capital Blue Cross | Admin | $473 | $22.52 |
| ConnectCare3 | Patient Advocate | $77 | $3.67 |