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Employer
312 Woodland Road, Mt. Pocono, PA 18344 · EIN 20-1454362 · Aug 1, 2024 to Jul 31, 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 $35,456
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | Everest Reinsurance Company | — | — | Comp not disclosed Premium $252 |
| Stop-loss | Fair American Insurance And Reinsurance Company | — | 377 | Comp not disclosed Premium $359,058 |
| Dental | The Guardian Life Insurance Company Of America | — | 420 | Comp not disclosed Premium $21,255 |
| Vision | Revivehealth | — | — | Schedule A not provided |
| Vision | National Vision Administrators, LLC | — | — | Schedule A not provided |
| Life | United Of Omaha Life Insurance Company | Fmlasource Inc | 629 | $9,634 21.0% of $45,883 |
| Life | United Of Omaha Life Insurance Company | Universal Employee Benefit Solution | 629 | $2,698 5.9% of $45,883 |
| AD&D | United Of Omaha Life Insurance Company | Universal Employee Benefit Solution | 202 | $4,429 5.9% of $75,656 |
| Other | United Of Omaha Life Insurance Company | Universal Employee Benefit Solution | 22 | $356 5.8% of $6,124 |
| Voluntary Short-Term Disability | United Of Omaha Life Insurance Company | Universal Employee Benefit Solution | 218 | $13,284 5.9% of $225,226 |
| Other | United Of Omaha Life Insurance Company | Universal Employee Benefit Solution | 22 | $501 5.8% of $8,657 |
| Other | United Of Omaha Life Insurance Company | Universal Employee Benefit Solution | 202 | $4,554 5.9% of $76,827 |
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 $140,056
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| The Benecon Group | Broker | $72,232 | $114.84 |
| Patchcoski, David | Broker | $59,358 | $94.37 |
| Highmark, Inc. | Admin | $8,466 | $13.46 |