Form 5500 · Employee benefit plan · WELLSVILLE, NY
JONES MEMORIAL HOSPITAL
The filing calls this plan JONES MEMORIAL HOSPITAL EMPLOYEE BENEFIT PLAN.
JONES MEMORIAL HOSPITAL of WELLSVILLE, NY is a 84-participant health care and social assistance employer whose group benefits are disclosed in its annual Form 5500 filing. Its broker of record is USI INSURANCE SERVICES LLC. Coverage is written through UNIVERA HEALTHCARE and 1 other carrier. The plan's most recent policy period ended in December.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 22-2807681 · plan 506 · plan year 2025, filed Jul 14, 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.
The filing carries code 4S: this plan is filing again after previously being exempt.
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, life and disability; the largest, with UNIVERA HEALTHCARE, covers 217 people.
The filing declares health, life, disability, 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 $3,793,466, with $147,929 in disclosed broker commissions — about 3.9% 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 all 2 contracts.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| UNIVERA HEALTHCARE | Health | 217 | Jan 1, 2026 | $3,409,501 | $93,056 |
| SYMETRA LIFE INSURANCE COMPANY | Life, Disability | 217 | Jan 1, 2026 | $383,965 | $54,873 |
Premium and claims on this contract
UNIVERA HEALTHCARE, contract 130376. For the contract year on this filing, the carrier reported $3,409,501 in premium earned and $4,282,867 in claims incurred. Dividing one by the other gives 126%.
- UNIVERA HEALTHCARE, contract 130376 reported $522,374 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.
Other plans filed by this employer
How this plan compares
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