| 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 | $2K | $6K | 11.40% |
| NATIONAL BENEFIT CENTER3 | 23825 COMMERCE PARK BEACHWOOD, OH 44122 | UNITED OF OMAHA LIFE INSURANCE COMPANY | — | $1K | $1K | 2.89% |
| TIC INC3 | 701 SAND LAKE RD ONALASKA, WI 54650 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $5K | $1K | $6K | 18.39% |
| NATIONAL BENEFIT CENTER3 | 23825 COMMERCE PARK BEACHWOOD, OH 44122 | UNITED OF OMAHA LIFE INSURANCE COMPANY | — | $896 | $896 | 2.90% |
| TIC INC3 | 701 SAND LAKE RD ONALASKA, WI 54650 | UNITED OF OMAHA LIFE INSURANCE COMPANY | $3K | $707 | $4K | 18.65% |
| NATIONAL BENEFIT CENTER3 | 23825 COMMERCE PARK BEACHWOOD, OH 44122 | UNITED OF OMAHA LIFE INSURANCE COMPANY | — | $606 | $606 | 3.13% |
| TIC INC3 | 701 SAND LAKE RD ONALASKA, WI 54650 | FIDELITY SECURITY LIFE INSURANCE COMPANY | $1K | — | $1K | 10.00% |
| DIRECT BENEFITS INC3 | 55 E 5TH ST, SUITE 500 SAINT PAUL, MN 55101 | FIDELITY SECURITY LIFE INSURANCE COMPANY | $865 | — | $865 | 6.00% |
| UNITED OF OMAHA LIFE INSURANCE CO5 | MUTUAL OF OMAHA PLAZA OMAHA, NE 68175 | UNITED OF OMAHA LIFE INSURANCE COMPANY | — | $3K | $3K | — |
| TIC INC3 | 701 SAND LAKE RD ONALASKA, WI 54650 | UNITED OF OMAHA LIFE INSURANCE COMPANY | — | $103 | $103 | — |
| NATIONAL BENEFIT CENTER3 | 23825 COMMERCE PARK BEACHWOOD, OH 44122 | UNITED OF OMAHA LIFE INSURANCE COMPANY | — | $89 | $89 | — |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| ALLEGIANCE BENEFIT PLAN MANAGEMENT EIN 81-0400550 BENEFIT ADMINISTRATOR | Claims processing; Contract Administrator; Recordkeeping and information management (computing, tabulating, data processing, etc.) Service code 12 | 2806 GARFIELD ST MISSOULA, MT 59806 | $34K |
| DDMN ASO, LLC EIN 41-1852523 BENEFIT ADMINISTRATOR | Contract Administrator; Claims processing Service code 12 | NW 6112 PO BOX 1450 MINNEAPOLIS, MN 55485 | $6K |
| ALLEGIANCE CARE MANAGEMENT INC EIN 03-0507057 ADMINISTRATION | Recordkeeping and information management (computing, tabulating, data processing, etc.); Contract Administrator Service code 13 | 2806 GARFIELD ST MISSOULA, MT 59806 | $5K |
| ALLEGIANCE COBRA SERVICES INC EIN 71-0916514 BENEFIT ADMINISTRATOR | Recordkeeping and information management (computing, tabulating, data processing, etc.); Contract Administrator; Claims processing Service code 12 | 2806 GARFIELD ST MISSOULA, MT 59806 | $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 | 104 | Currently employed and enrolled or eligible. |
| Total participants (= "Plan participants" tile) | 104 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Health (medical) | SUN LIFE ASSURANCE COMPANY OF CANADA | 104 | $494K |
| Vision | FIDELITY SECURITY LIFE INSURANCE COMPANY | 136 | $14K |
| Life insurance(2 contracts) | UNITED OF OMAHA LIFE INSURANCE COMPANY | 119 | $69K |
| Short-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 118 | $0 |
| Long-term disability | UNITED OF OMAHA LIFE INSURANCE COMPANY | 118 | $31K |
| Stop-loss / reinsurancereinsurance | SUN LIFE ASSURANCE COMPANY OF CANADA | 104 | $494K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 136 | — |
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.