| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES INC. | 3000 WEST MACARTHUR BOULEVARD SUITE 320 SANTA ANA, CA 92704 | KAISER FOUNDATION HEALTH PLAN INC | $273K | $0 | $273K | 2.19% |
| CLEVIDENCE INSURANCE SERVICES INC5 Filed as: CLEVIDENCE INSURANCE SERVICES INC. | 3000 WEST MACARTHUR BOULEVARD SUITE 320 SANTA ANA, CA 92704 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $0 | $212K | $212K | 5.79% |
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES INC. | 3000 WEST MACARTHUR BOULEVARD SUITE 320 SANTA ANA, CA 92704 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $184K | — | $184K | 5.03% |
| FMLASOURCE INC5 Filed as: FMLASOURCE INC. | 455 NORTH CITYFRONT PLAZA DRIVE 13TH FLOOR CHICAGO, IL 60611 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $0 | $39K | $39K | 1.05% |
| THOMAS EDWARD BRADBURY3 | 35 BLUE HERON DRIVE FLETCHER, NC 28732 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $768 | $0 | $768 | 0.02% |
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES INC. | 3000 WEST MACARTHUR BOULEVARD SUITE 320 SANTA ANA, CA 92704 | AETNA LIFE INSURANCE COMPANY | $169K | $0 | $169K | 4.84% |
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES INC. | 3000 WEST MACARTHUR BOULEVARD SUITE 320 SANTA ANA, CA 92704 | AETNA LIFE INSURANCE COMPANY | $0 | $3K | $3K | 0.07% |
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES INC. | 3000 WEST MACARTHUR BOULEVARD SUITE 320 SANTA ANA, CA 92704 | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | $6K | $0 | $6K | 2.12% |
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES INC. | 3000 WEST MACARTHUR BOULEVARD SUITE 320 SANTA ANA, CA 92704 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $3K | $0 | $3K | 10.00% |
| CLEVIDENCE INSURANCE SERVICES INC5 Filed as: CLEVIDENCE INSURANCE SERVICES INC. | 3000 WEST MACARTHUR BOULEVARD SUITE 320 SANTA ANA, CA 92704 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $0 | $1K | $1K | 4.61% |
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES INC. | 3000 WEST MACARTHUR BOULEVARD SUITE 320 SANTA ANA, CA 92704 | MUTUAL OF OMAHA INSURANCE COMPANY | $3K | $0 | $3K | 9.14% |
| CLEVIDENCE INSURANCE SERVICES INC5 Filed as: CLEVIDENCE INSURANCE SERVICES INC. | 3000 WEST MACARTHUR BOULEVARD SUITE 320 SANTA ANA, CA 92704 | MUTUAL OF OMAHA INSURANCE COMPANY | $0 | $2K | $2K | 6.00% |
| CLEVIDENCE INSURANCE SERVICES INC3 Filed as: CLEVIDENCE INSURANCE SERVICES INC. | 3000 WEST MACARTHUR BOULEVARD SUITE 320 SANTA ANA, CA 92704 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $1K | $0 | $1K | 4.20% |
No Schedule C service providers reported on this filing.
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 | 4,227 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 73 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 4,300 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | KAISER FOUNDATION HEALTH PLAN INC | 2,503 | $12.5M |
| Dental | AETNA LIFE INSURANCE COMPANY | 8,535 | $3.5M |
| Vision | ANTHEM BLUE CROSS LIFE AND HEALTH INSURANCE COMPANY | 7,132 | $305K |
| Life insurance(3 contracts) | UNITED OF OMAHA LIFE INSURANCE COMPANY | 4,895 | $3.7M |
| Short-term disability(2 contracts) | UNITED OF OMAHA LIFE INSURANCE COMPANY | 68 | $55K |
| Long-term disability(2 contracts) | UNITED OF OMAHA LIFE INSURANCE COMPANY | 68 | $55K |
| Prescription drug | KAISER FOUNDATION HEALTH PLAN INC | 2,503 | $12.5M |
| Other(4 contracts, 2 carriers) | UNITED OF OMAHA LIFE INSURANCE COMPANY | 4,895 | $3.7M |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 8,535 | — |
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."
No prospect flags tripped on this filing.