| Broker | Address | Carrier | Commissions | Fees | Total comp | % of premium |
|---|---|---|---|---|---|---|
| WELLS FARGO INSURANCE SERVICES3 | 2975 REGENT BLVD IRVING, TX 75063 | DELTA DENTAL OF OHIO | $1K | — | $1K | 0.27% |
| MERCER HEALTH AND BENEFITS, LLC3 Filed as: MERCER HEALTH AND BENEFITS LLC | 4565 PAYSPHERE CIR CHICAGO, IL 60674 | DELTA DENTAL OF OHIO | $878 | — | $878 | 0.17% |
| WELLS FARGO INSURANCE SERVICES3 | PO BOX 203417 DALLAS, TX 75320 | SUN LIFE ASSURANCE COMPANY OF CANADA | $43K | — | $43K | 10.00% |
| Provider | Services | Address | Compensation |
|---|---|---|---|
| UNITED HEALTHCARE SERVICES INC EIN 41-1289245 THIRD PARTY ADMINISTRATOR | Claims processing; Other commissions; Other services Service code 12 | — | $361K |
| COMMUNITY INSURANCE COMPANY EIN 31-1440175 THIRD PARTY ADMINISTRATOR | Other commissions; Other services; Insurance agents and brokers; Contract Administrator; Recordkeeping and information management (computing, tabulating, data processing, etc.); Float revenue; Other fees; Claims processing; Insurance brokerage commissions and fees Service code 12 | — | $173K |
| DELTA DENTAL OF OHIO EIN 31-0685339 BENEFIT ADMINISTATOR | Claims processing; Contract Administrator Service code 12 | — | $34K |
| SUN LIFE ASSURANCE COMPANY OF CANAD EIN 38-1082080 THIRD PARTY ADMINISTRATOR | Claims processing Service code 12 | — | $28K |
| MEDICAL BENEFITS ADMINISTRATORS EIN 31-1249371 CONTRACT | Plan Administrator Service code 14 | — | $18K |
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 | 730 | Currently employed and enrolled or eligible. |
| Retired/separated still receiving benefits | 3 | Continuation coverage (COBRA, retiree health). |
| Total participants (= "Plan participants" tile) | 733 | Active + retired/separated + beneficiaries. No dependents. |
| Coverage | Top carrier | Persons covered EOY | Premium |
|---|---|---|---|
| Dental | DELTA DENTAL OF OHIO | 1,764 | $502K |
| Life insurance | SUN LIFE ASSURANCE COMPANY OF CANADA | 889 | $427K |
| Long-term disability | SUN LIFE ASSURANCE COMPANY OF CANADA | 889 | $427K |
| Stop-loss / reinsurancereinsurance | UNITED HEALTHCARE INSURANCE COMPANY | 1,631 | $493K |
| Other | SUN LIFE ASSURANCE COMPANY OF CANADA | 889 | $427K |
| Persons covered (= "Persons covered" tile) | Max across the rows above | 1,764 | — |
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.