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Employer
612 Main St., Stroudsburg, PA 18360 · EIN 27-1767899 · Jan 1, 2022 to Dec 31, 2022
Plan year 2022
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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 $12,872
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | Everest Reinsurance Company | — | 79 | Comp not disclosed Premium $260,999 |
| Dental | Delta Dental-Sba Pa | Bsi Corporate Benefits, Inc. | 91 | $6,163 9.8% of $62,604 |
| Vision | Vision Service Plan | Bsi Corporate Benefits, Inc. | 84 | $670 7.9% of $8,479 |
| Vision | Vision Service Plan | Emerson Reid & Co. | 84 | $420 5.0% of $8,479 |
| Life | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 113 | $792 5.2% of $15,335 |
| Other | United Of Omaha Life Insurance Companuy | Bsi Corporate Benefits, Inc. | 113 | $2,301 15.0% of $15,335 |
| Other | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 113 | $1,370 15.0% of $9,135 |
| Vol Life | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 55 | $1,156 20.0% of $5,780 |
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 $70,881
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| Bsi Corporate Benefits LLC | Broker | $49,833 | $441.00 |
| The Benecon Group | Broker | $18,630 | $164.87 |
| Healthiest You | Admin | $8,662 | $76.65 |
| ConnectCare3 | Patient Advocate | $5,125 | $45.35 |
| Highmark (Central) | Admin | $-730 | $-6.46 |
| Highmark Bcbc Nepa | Admin | $-10,639 | $-94.15 |