| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| CORPORATE ONE BENEFITS3 Filed as: CORPORATE ONE BENEFITS, INC | 1650 NORTH COUNTY LINE ST SUITE 200 PO BOX 906 FOSTORIA, OH 44830 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $6K | — | $6K | 15.00% |
| CORPORATE ONE BENEFITS3 Filed as: CORPORATE ONE BENEFITS, INC | 1650 NORTH COUNTY LINE ST SUITE 200 PO BOX 906 FOSTORIA, OH 44830 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $3K | — | $3K | 11.77% |
| CORPORATE ONE BENEFITS3 Filed as: CORPORATE ONE BENEFITS, INC | 1650 NORTH COUNTY LINE ST SUITE 200 PO BOX 906 FOSTORIA, OH 44830 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $2K | — | $2K | 10.00% |
| CORPORATE ONE BENEFITS3 Filed as: CORPORATE ONE BENEFITS, INC | 1650 NORTH COUNTY LINE ST SUITE 200 PO BOX 906 FOSTORIA, OH 44830 | THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA | $5K | — | $5K | 28.61% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| MUTUAL OF OMAHA INSURANCE COMPANY EIN 47-0322111 CONTRACT | Plan Administrator Service code 14 | 3300 MUTUAL OF OMAHA PLAZA OMAHA, NE 68175 | $95K |
| MEDICAL BENEFITS ADMINISTRATORS EIN 31-1249371 CONTRACT | Plan Administrator Service code 14 | — | $60K |
| CORPORATE ONE BENEFITS EIN 34-1834526 BROKER | Insurance agents and brokers Service code 22 | 1650 NORTH COUNTY LINE ST SUITE 200 - PO BOX 906 FOSTORIA, OH 44830 | $54K |
| OHIO HEALTH CHOICE EIN 34-1381358 CONTRACT | Other fees Service code 99 | — | $30K |
| THE GUARDIAN LIFE INSURANCE COMPANY EIN 13-5123390 CONTRACT | Plan Administrator Service code 14 | — | $18K |
| MEDICAL BENEFITS MUTUAL LIFE INS CO EIN 31-4210910 CONTRACT | Plan Administrator Service code 14 | — | $5K |
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 | 235 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 235 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Dental | THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA | 202 | $18K |
| Vision | THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA | 202 | $18K |
| Life insurance(2 contracts) | UNITED OF OMAHA LIFE INSURANCE COMPANY | 269 | $65K |
| Stop-loss / reinsurancereinsurance | MUNICH/AMERICAN ALTERNATIVE INSURANCE CORPORATION | 201 | $267K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 269 | — |
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."
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.