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Employer
3475 East Market Street, York, PA 17402 · EIN 23-2000402 · Jan 1, 2021 to Dec 31, 2021
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 $4,718
| Coverage | Carrier | Broker | Lives | Direct comp |
|---|---|---|---|---|
| Stop-loss | HM Life Insurance Company | — | 20 | Comp not disclosed Premium $90,093 |
| Life | United Of Omaha Life Insurance Company | Silberstein Insurance Group | 33 | $866 15.1% of $5,720 |
| Life | United Of Omaha Life Insurance Company | National Benefit Center | 33 | $196 3.4% of $5,720 |
| Other | United Of Omaha Life Insurance Company | Silberstein Insurance Group | 33 | $1,373 15.1% of $9,067 |
| Other | United Of Omaha Life Insurance Company | National Benefit Center | 33 | $310 3.4% of $9,067 |
| Other | United Of Omaha Life Insurance Company | Silberstein Insurance Group | 33 | $1,683 20.2% of $8,318 |
| Other | United Of Omaha Life Insurance Company | National Benefit Center | 33 | $290 3.5% of $8,318 |
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 $18,551
| Party | Type | Amount | $ / Enrolled / Year |
|---|---|---|---|
| The Benecon Group, LLC | Broker | $6,203 | $163.24 |
| Frank N. Lotman | Broker | $6,096 | $160.42 |
| Highmark | Admin | $4,957 | $130.45 |
| Connectcare 3 | Patient Advocate | $1,295 | $34.08 |