Form 5500 · Employee benefit plan · HARRISBURG, PA
CAPITAL BLUE CROSS
The filing calls this plan CAPITAL BLUE CROSS MEDICAL AND LIFE INSURANCE PLAN FOR DISABLED FORMER EMPLOYEES.
Public Form 5500 records show how CAPITAL BLUE CROSS of HARRISBURG, PA, a finance and insurance employer, structures its employee benefits. Its broker of record is CONSOLIDATED BENEFITS, INC.. Coverage is written through DEARBORN LIFE INSURANCE COMPANY. The plan's most recent policy period ended in December.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 23-0455154 · plan 511 · plan year 2024, filed Oct 2, 2025
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How this plan is funded
Funding not settled by the filing
The filing does not report enough to settle how this plan pays for benefits.
Benefits declared on this filing
Also declared: other welfare.
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
The filing discloses a single insured line, life, through DEARBORN LIFE INSURANCE COMPANY, covering 28 people.
The filing declares life, health, dental and vision. Health, 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 $8,703, with $434 in disclosed broker commissions — about 5% of premium.
The most recent policy period ended in December, and the plan year ends December 31. Group contracts typically renew on that annual cycle.
At 27 participants this is a small group; Form 5500 is required once a welfare plan reaches 100 participants, or when it is funded through insurance contracts.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| DEARBORN LIFE INSURANCE COMPANY | Life | 28 | Jan 1, 2025 | $8,703 | $434 |
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. The service providers are named on Schedule C of this filing. We publish company names only.
Other plans filed by this employer
How this plan compares
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