| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| TIC INC3 | 701 SAND LAKE RD ONALASKA, WI 54650 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $4K | — | $4K | 8.23% |
| TIC INC3 | 701 SAND LAKE RD ONALASKA, WI 54650 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $4K | — | $4K | 15.00% |
| TIC INC3 | 701 SAND LAKE RD ONALASKA, WI 54650 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $3K | — | $3K | 15.00% |
| TIC INC3 | 701 SAND LAKE RD ONALASKA, WI 54650 | FIDELITY SECURITY LIKE INSURANCE COMPANY | $1K | — | $1K | 10.00% |
| DIRECT BENEFITS INC3 Filed as: DIRECT BENEFITS, INC | 55 E 5TH STREET, STE 500 ST PAUL, MN 55101 | FIDELITY SECURITY LIKE INSURANCE COMPANY | $651 | — | $651 | 6.01% |
| UNITED OF OMAHA LIFE INSURANCE CO5 | MUTUAL OF OMAHA PLAZA OMAHA, NE 68175 | UNITED OF OMAHA LIFE INSURANCE COMPANY | — | $3K | $3K | — |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| ALLEGIANCE BENEFIT PLAN MANAGEMENT EIN 81-0400550 ADMINISTRATIVE | Recordkeeping and information management (computing, tabulating, data processing, etc.); Contract Administrator; Claims processing Service code 12 | 2806 GARFIELD ST MISSOULA, MT 598063018 | $33K |
| DDMN ASO, LLC EIN 41-1852523 ADMINISTRATOR | Contract Administrator; Claims processing Service code 12 | NW 6112 PO BOX 1450 MINNEAPOLIS, MN 55485 | $6K |
| ALLEGIANCE CARE MANAGEMENT INC EIN 03-0507057 ADMINISTRATIVE SERVICES | Contract Administrator; Recordkeeping and information management (computing, tabulating, data processing, etc.); Claims processing Service code 12 | 2806 GARFIELD ST MISSOULA, MT 598063018 | $5K |
| ALLEGIANCE COBRA SERVICES INC EIN 71-0916514 ADMINISTRATIVE SERVICES | Recordkeeping and information management (computing, tabulating, data processing, etc.); Contract Administrator; Claims processing Service code 12 | 2806 GARFIELD ST MISSOULA, MT 598063018 | $3K |
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 | 109 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 109 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | SUN LIFE ASSURANCE COMPANY OF CANADA | 109 | $434K |
| Vision | FIDELITY SECURITY LIKE INSURANCE COMPANY | 58 | $11K |
| Life insurance(2 contracts) | UNITED OF OMAHA LIFE INSURANCE COMPANY | 121 | $66K |
| Short-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 120 | $0 |
| Long-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 120 | $29K |
| Stop-loss / reinsurancereinsurance | SUN LIFE ASSURANCE COMPANY OF CANADA | 109 | $434K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 121 | — |
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."
The primary carrier changed from prior filing. The plan is already willing to move; opportunity to re-pitch on the next cycle.