Form 5500 · Employee benefit plan · UTICA, NY
ADIRONDACK BANK
The filing calls this plan ADIRONDACK BANK WELFARE BENEFIT PLAN.
Public Form 5500 records show how ADIRONDACK BANK of UTICA, NY, a finance and insurance employer, structures its employee benefits. Its broker of record is AFS AGENCY. Coverage is written through EXCELLUS BLUE CROSS BLUE SHIELD and 1 other carrier. The plan's most recent policy period ended in December.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 15-0438700 · plan 501 · plan year 2025, filed Jul 1, 2026
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How this plan is funded
Fully insured as reported
The filing reports medical coverage through an insurance contract on Schedule A, and no money paid for benefits by the plan itself.
Benefits declared on this filing
Also declared: death benefits.
Declared benefits are the plan’s own line 8b codes on Form 5500. “Not on Schedule A” means no insured contract for that line appears on this filing. That usually means the benefit is self-funded, or it sits under a different plan number.
Persons covered is the count the carrier filed for that policy at the end of its policy year, and it can include dependents. Participants is the plan's own count at the start of its plan year. The two count different people, so a covered figure can be larger.
Plan brief
Schedule A lists 2 insured contracts covering health and life; the largest, with EXCELLUS BLUE CROSS BLUE SHIELD, covers 110 people.
The filing declares health, life, dental and vision. Dental and vision appear with no insured contract on Schedule A. That coverage may be self-funded, or placed with a carrier that is not on this filing.
Reported premium across the insured contracts is $2,210,162, with $92,710 in disclosed broker commissions — about 4.2% of premium.
The health contract's policy period ended in December, while at least one ancillary line's policy period ended in June. The plan is on a split renewal cycle.
AFS AGENCY is the broker of record on 1 of the 2 contracts; the rest name a different broker or none.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| EXCELLUS BLUE CROSS BLUE SHIELD | Health | 110 | Jan 1, 2026 | $2,137,441 | $74,529 |
| COMPANION LIFE INSURANCE COMPANY | Life | 194 | Jul 1, 2025 | $72,721 | $18,181 |
Premium and claims on this contract
EXCELLUS BLUE CROSS BLUE SHIELD, contract 00019622. For the contract year on this filing, the carrier reported $2,137,441 in premium earned and $2,485,134 in claims incurred. Dividing one by the other gives 116%.
- EXCELLUS BLUE CROSS BLUE SHIELD, contract 00019622 reported $305,174 in retention.
Retention is what the carrier kept of the premium after claims, as reported: administration, commissions and other charges.
Only experience-rated contracts report these figures, so most filings leave them blank.
Covered = persons covered at policy year end, as filed on Schedule A for that policy — often certificates or one class, not the whole plan. Premium = the filing’s own premium/charges figure; “—” means not credibly reported.
Administrator and service providers
The plan administrator is from line 3a of the main form. We publish company names only.
Other plans filed by this employer
How this plan compares
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