Form 5500 · Employee benefit plan · OSHKOSH, WI
EVERGREEN RETIREMENT COMMUNITY, INC.
The filing calls this plan EVERGREEN RETIREMENT COMMUNITY, INC. MEDICAL PROTECTION PLAN.
EVERGREEN RETIREMENT COMMUNITY, INC. of OSHKOSH, WI insures vision, life and disability coverage for its employees, per Schedule A of its Form 5500. Its broker of record is USI INSURANCE SERVICES LLC. Coverage is written through UNUM LIFE INSURANCE COMPANY OF AMERICA and 2 other carriers. The plan's most recent policy period ended in December.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 39-1081800 · plan 502 · plan year 2025, filed Jun 10, 2026
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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
One contract on this filing does not say which benefits it covers, so a line above may be insured by it.
Also declared: death benefits, 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
Schedule A lists 3 insured contracts covering vision, life and disability; the largest, with UNUM LIFE INSURANCE COMPANY OF AMERICA, covers 191 people.
The filing declares vision, life, disability, health and dental. Health and dental appear with no insured contract on Schedule A. That coverage may be self-funded, placed with a carrier that is not on this filing, or written on the contract here that does not say what it covers.
Reported premium across the insured contracts is $60,505, with $5,831 in disclosed broker commissions — about 9.6% 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.
USI INSURANCE SERVICES LLC is the broker of record on 2 of the 3 contracts; the rest name a different broker or none.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| UNUM LIFE INSURANCE COMPANY OF AMERICA | Life, Disability | 191 | Jan 1, 2026 | $30,483 | $4,623 |
| HUMANA INSURANCE COMPANY | Vision | 87 | Jan 1, 2026 | $13,822 | $1,208 |
| VITAL TRACTION, LLC | — | 15 | Jan 1, 2026 | $16,200 | $0 |
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.
Reported to OSHA
Reported to OSHA for 2025: 307 employees, 9 recordable cases, 7 days away from work.
Source: OSHA Injury Tracking Application establishment data, 2025.
Other plans filed by this employer
How this plan compares
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