| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| GALLAGHER BENEFIT SERVICES, INC. Filed as: GALLAGHER BENEFIT SERVICES | 2850 GOLF ROAD ROLLING MEADOWS, IL 60008 | CIGNA HEALTH & LIFE INSURANCE COMPANY | $42K | — | $42K | 7.16% |
| BOLLINGER INC | — | CIGNA HEALTH & LIFE INSURANCE COMPANY | $24K | — | $24K | 4.09% |
| GALLAGHER BENEFIT SERVICES, INC. | 300 FELLOWSHIP ROAD MT. LAUREL, NJ 08054 | DELTA DENTAL OF NEW JERSEY, INC. | $10K | — | $10K | 12.10% |
| GALLAGHER BENEFIT SERVICES, INC. | 2850 GOLF ROAD 5TH FLOOR ROLLING MEADOWS, IL 60008 | UNUM LIFE INSURANCE COMPANY OF AMERICA | $7K | $879 | $8K | 12.32% |
| GALLAGHER BENEFIT SERVICES, INC. Filed as: GALLAGHER BENEFIT SERVICES | 2850 GOLF ROAD ROLLING MEADOWS, IL 60008 | VISION SERVICE PLAN | $893 | — | $893 | 6.22% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| ACTIVE & FIT-AMERICAN SPECIALTY HEA EIN 33-0883241 | Claims processing; Contract Administrator; Non-monetary compensation; Named fiduciary; Participant communication; Direct payment from the plan; Float revenue; Other services Service code 12 | 10221 WATERRIDGE CIRCLE SAN DIEGO, CA 92121 | $0 |
| OMADA COMPLETE, INC. EIN 45-2355015 | Other services; Float revenue; Contract Administrator; Claims processing; Non-monetary compensation; Named fiduciary; Direct payment from the plan; Participant communication Service code 12 | 500 SANSOME ST #200 SAN FRANCISCO, CA 94111 | $0 |
| OMADA HEALTH INC EIN 45-2355015 | Named fiduciary; Non-monetary compensation; Claims processing; Direct payment from the plan; Float revenue; Other services; Participant communication; Contract Administrator Service code 12 | 500 SANSOME ST #200 SAN FRANCISCO, CA 94111 | $0 |
Benefits declared on the Form 5500 main form (✓ = also has a Schedule A insurance contract; otherwise the benefit is funded out of plan assets or via a Schedule C TPA).
The plan reports several different headcounts depending on which form you read. Each one measures a different slice of the population.
| Active participants | 360 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 360 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | CIGNA HEALTH & LIFE INSURANCE COMPANY | 128 | $585K |
| Dental | DELTA DENTAL OF NEW JERSEY, INC. | 140 | $83K |
| Vision | VISION SERVICE PLAN | 111 | $14K |
| Life insurance | UNUM LIFE INSURANCE COMPANY OF AMERICA | 360 | $64K |
| Short-term disability | UNUM LIFE INSURANCE COMPANY OF AMERICA | 360 | $64K |
| Long-term disability | UNUM LIFE INSURANCE COMPANY OF AMERICA | 360 | $64K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 360 | — |
Why the numbers differ. Form 5500 line 6 counts employees + retirees + beneficiaries; no dependents. Schedule A persons-covered counts everyone enrolled, including spouses and children, so it usually exceeds line 6 by 30-60% on a working-age workforce. The medical row is normally the broadest single line because it has the highest take-up; dental/vision/life often dip below it. Stop-loss / reinsurance contracts sometimes report the carrier's full underwriting pool rather than this filer's headcount; the row is shown for transparency but shouldn't be read as "people in this plan."
Broker compensation exceeds 5% of premium. Either a small-plan minimum-fee dynamic or an inefficient broker structure ripe for a counter-bid.