| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| BROOKS AGENCY INC3 Filed as: BROOKS INSURANCE | 1120 MADISON AVE. TOLEDO, OH 43604 | DELTA DENTAL OF OHIO | $886 | — | $886 | 1.91% |
| STAPLETON INSURANCE & RISK MGMT INC3 Filed as: STAPLETON INSURANCE & RISK MGMT | PO BOX 1118 SYLVANIA, OH 43560 | DELTA DENTAL OF OHIO | $609 | — | $609 | 1.31% |
| USI INSURANCE SERVICES LLC3 | PO BOX 62889 VIRGINIA BEACH, VA 23466 | DELTA DENTAL OF OHIO | $503 | — | $503 | 1.08% |
| BROOKS INS AGENCY INC Filed as: BROOKS INS AGCY INC | 1120 MADISON AVENUE TOLEDO, OH 43604 | NATIONAL GUARDIAN LIFE INSURANCE COMPANY | — | — | $0 | — |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| MEDICAL MUTUAL OF OHIO EIN 34-1922587 CONTRACT SERVICE PROVIDER | Contract Administrator; Claims processing Service code 12 | 2060 EAST 9TH STREET CLEVELAND, OH 44115 | $61K |
| BROOKS INSURANCE EIN 31-1440175 CONTRACT BROKER | Other commissions; Insurance agents and brokers; Insurance brokerage commissions and fees Service code 22 | 1120 MADISON AVE. TOLEDO, OH 43604 | $0 |
| STAPLETON INSURANCE & RISK MGMT EIN 34-1014223 CONTRACT ADVISOR | Insurance agents and brokers; Consulting (general) Service code 16 | PO BOX 1118 SYLVANIA, OH 43560 | $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 | 119 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 0 | Continuation coverage (COBRA, retiree health). |
| Retired/separated still eligible | 0 | Vested but not currently using benefits. |
| Total participants (= "Plan participants" tile) | 119 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Dental | DELTA DENTAL OF OHIO | 0 | $46K |
| Vision | NATIONAL GUARDIAN LIFE INSURANCE COMPANY | 195 | $0 |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 195 | — |
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."
Top carrier holds >85% of premium. If that carrier hits a rate increase, the entire plan moves.
Schedule A presence shifted between filings (insured ↔ self-funded, or new contracts added/removed). Capture the transition window.