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Employer
1660 Blue Mountain Drive, Palmerton, PA 18071 · EIN 23-1919081 · Apr 1, 2021 to Mar 31, 2022
Plan year 2021
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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 $28,809
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | Everest Reinsurance Company | — | — | Comp not disclosed Premium $90,426 |
| Medical | Metropolitan Life Insurance Company | Joe Fernandez | 40 | $3,863 52.0% of $7,424 |
| Medical | Metropolitan Life Insurance Company | Burnham Benefits Ins. Services | 40 | $1,261 17.0% of $7,424 |
| Medical | Metropolitan Life Insurance Company | Bsi Corporate Benefits, Inc. | 40 | $439 5.9% of $7,424 |
| Medical | Metropolitan Life Insurance Company | Burnham Benefits Ins. Services | 40 | $117 1.6% of $7,424 |
| Medical | Metropolitan Life Insurance Company | Bsi Corporation Benefits LLC | 43 | $129 2.4% of $5,431 |
| Medical | Metropolitan Life Insurance Company | Burnham Benefits Ins Services | 43 | $93 1.7% of $5,431 |
| Medical | Metropolitan Life Insurance Company | Joe Fernandez | 43 | $2,779 51.2% of $5,431 |
| Medical | Metropolitan Life Insurance Company | Burnham Benefits Ins. Services | 43 | $1,138 21.0% of $5,431 |
| Medical | Dominion National | J. P. Warner Associates, Inc. | 7 | $2,572 9.4% of $27,364 |
| Medical | Dominion National | Bsi Corporate Benefits, Inc. | 7 | $770 2.8% of $27,364 |
| Vision | Fsl | Burnham Benefits Ins. Services | 139 | $162 3.9% of $4,114 |
| Vision | Fsl | Bsi Corporate Benefits, Inc. | 139 | $39 0.9% of $4,114 |
| Life | Trustmark Insurance Company | Bsi Corporate Benefits, Inc. | 29 | $694 8.9% of $7,759 |
| Life | Trustmark Insurance Company | Burnham Benefits Ins. Services | 29 | $4 0.1% of $7,759 |
| Life | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 37 | $1,201 15.0% of $8,017 |
| Life | United Of Omaha Life Insurance Company | Burnham Benefits Ins. Services | 37 | $441 5.5% of $8,017 |
| Life | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 81 | $242 11.2% of $2,159 |
| Life | United Of Omaha Life Insurance Company | Burnham Benefits Ins. Services | 81 | $74 3.4% of $2,159 |
| Other | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 81 | $1,686 9.8% of $17,273 |
| Other | United Of Omaha Life Insurance Company | Burnham Benefits Ins. Services | 81 | $668 3.9% of $17,273 |
| Critical Illness And Accident | Metropolitan Life Insurance Company | Joe Fernandez | 40 | $5,462 57.5% of $9,506 |
| Critical Illness And Accident | Metropolitan Life Insurance Company | Burnham Benefits Ins. Services | 40 | $1,808 19.0% of $9,506 |
| Critical Illness And Accident | Metropolitan Life Insurance Company | Bsi Corporation Benefits LLC | 40 | $552 5.8% of $9,506 |
| Critical Illness And Accident | Metropolitan Life Insurance Company | Burnham Benefits Ins Services | 40 | $148 1.6% of $9,506 |
| Other | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 81 | $1,812 10.1% of $17,991 |
| Other | United Of Omaha Life Insurance Company | Burnham Benefits Ins. Services | 81 | $655 3.6% of $17,991 |
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 $78,147
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| Bsi Corporation Benefits | Broker | $33,778 | $243.01 |
| The Benecon Group, LLC | Broker | $16,423 | $118.15 |
| Highmark | Admin | $21,578 | $155.24 |
| Connectcare 3 | Patient Advocate | $3,435 | $24.71 |
| Healthiest You | Service Provider | $2,933 | $21.10 |