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Employer
84 West South Street, Wilkes- Barre, PA 18766 · EIN 24-0795506 · Jan 1, 2025 to Dec 31, 2025
Plan year 2025
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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 $31,034
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Vision | National Vision Administrators, LLC | — | 697 | Comp not disclosed Premium $40,879 |
| Life | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 538 | $7,407 7.6% of $97,154 |
| Life | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 538 | $3,150 3.2% of $97,154 |
| AD&D | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 184 | $5,139 7.7% of $66,813 |
| AD&D | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 184 | $3,150 4.7% of $66,813 |
| Other | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 501 | $6,365 7.4% of $85,988 |
| Other | United Of Omaha Life Insurance Company | Bsi Corporate Benefits, Inc. | 501 | $2,580 3.0% of $85,988 |
| EAP | United Of Omaha Life Insurance Company | — | — | Schedule A not provided |
| Cancer | Sun Life Assurance Company | Bsi Corporate Benefits, Inc. | 97 | $3,243 14.8% of $21,954 |
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 $14,939
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| Lehigh Valley Business | Broker | $240 | $0.34 |
| United Concordia Companies, Inc. | Admin | $14,699 | $21.09 |