Form 5500 · Employee benefit plan · HOUSTON, TX
CLEAN ROYALTIES, LLC
The filing calls this plan CLEAN ROYALTIES EMPLOYEE BENEFITS HEALTH PLAN.
CLEAN ROYALTIES, LLC of HOUSTON, TX files a Form 5500 with the U.S. Department of Labor disclosing its employee benefit plan. Its broker of record is ACRISURE LLC. Coverage is written through DELTA DENTAL PLAN OF VERMONT, INC. and 2 other carriers. The plan's most recent policy period ended in June.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 99-4276838 · plan 501 · plan year 2025, filed Feb 19, 2026
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How this plan is funded
Funding not settled by the filing
The filing does not report enough to settle how this plan pays for benefits.
Benefits declared on this filing
Also declared: death benefits, other welfare.
Declared benefits are the plan’s own line 8b codes on Form 5500. “Not on Schedule A” means no insured contract for that line appears on this filing. That usually means the benefit is self-funded, or it sits under a different plan number.
Persons covered is the count the carrier filed for that policy at the end of its policy year, and it can include dependents. Participants is the plan's own count at the start of its plan year. The two count different people, so a covered figure can be larger.
Plan brief
Schedule A lists 3 insured contracts covering dental, vision, life and disability; the largest, with DELTA DENTAL PLAN OF VERMONT, INC., covers 258 people.
The filing declares dental, vision, life, disability and health. Health appears with no insured contract on Schedule A. That coverage may be self-funded, or placed with a carrier that is not on this filing.
Reported premium across the insured contracts is $173,442, with $8,370 in disclosed broker commissions — about 4.8% of premium.
The most recent policy period ended in June, and the plan year ends June 30. Group contracts typically renew on that annual cycle.
ACRISURE LLC is the broker of record on 1 of the 3 contracts; the rest name a different broker or none.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| STANDARD INSURANCE COMPANY | Life, Disability | 135 | Jul 1, 2025 | $83,378 | $5,087 |
| DELTA DENTAL PLAN OF VERMONT, INC. | Dental | 258 | Jul 1, 2025 | $90,064 | $3,283 |
| VISION SERVICE PLAN | Vision | 135 | Jul 1, 2025 | — | $0 |
Premium and claims on this contract
STANDARD INSURANCE COMPANY, contract 164138. For the contract year on this filing, the carrier reported $83,378 in premium earned and $14,995 in claims incurred. Dividing one by the other gives 18%.
- STANDARD INSURANCE COMPANY, contract 164138 reported $68,386 in retention.
Retention is what the carrier kept of the premium after claims, as reported: administration, commissions and other charges.
Only experience-rated contracts report these figures, so most filings leave them blank.
Covered = persons covered at policy year end, as filed on Schedule A for that policy — often certificates or one class, not the whole plan. Premium = the filing’s own premium/charges figure; “—” means not credibly reported.
Administrator and service providers
The plan administrator is from line 3a of the main form. We publish company names only.
Reported to OSHA
Reported to OSHA for 2025: 11 employees, 0 recordable cases, 0 days away from work.
Source: OSHA Injury Tracking Application establishment data, 2025.
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