Form 5500 · Employee benefit plan · FARMINGTON, ME
ORIGIN BJJ
The filing calls this plan ORIGIN BJJ WRAP PLAN.
Public Form 5500 records show how ORIGIN BJJ of FARMINGTON, ME, a other services employer, structures its employee benefits. Its broker of record is PAYCHEX INSURANCE AGENCY INC. Coverage is written through UNITEDHEALTHCARE INSURANCE COMPANY. The plan's most recent policy period ended in September.
Sourced from U.S. DOL EFAST2 Form 5500 · EIN 45-5052992 · plan 501 · plan year 2025, filed Jul 7, 2026
Get an email when this employer files a new Form 5500, and again about four months before its plan renews.
17 other employer plans in Maine have policy years ending in September. See the full list on the renewal calendar, or ask for it in Claude or ChatGPT.
How this plan is funded
Fully insured as reported
The filing reports medical coverage through an insurance contract on Schedule A, and no money paid for benefits by the plan itself.
Benefits declared on this filing
Also declared: 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 2 insured contracts covering health, dental, vision, life and disability; the largest, with UNITEDHEALTHCARE INSURANCE COMPANY, covers 370 people.
Reported premium across the insured contracts is $1,214,215, with $45,409 in disclosed broker commissions — about 3.7% of premium.
The most recent policy period ended in September, and the plan year ends September 30. Group contracts typically renew on that annual cycle.
PAYCHEX INSURANCE AGENCY INC is the broker of record on all 2 contracts.
Schedule A insurance contracts
| Carrier | Benefits | Covered | Renews | Premium | Commission |
|---|---|---|---|---|---|
| UNITEDHEALTHCARE INSURANCE COMPANY | Health, Dental, Vision | 370 | Oct 1, 2025 | $1,114,757 | $34,795 |
| UNITEDHEALTHCARE INSURANCE COMPANY | Life, Disability | 331 | Oct 1, 2025 | $99,458 | $10,614 |
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.
Reported to OSHA
Reported to OSHA for 2025: 96 employees, 4 recordable cases, 37 days away from work.
Source: OSHA Injury Tracking Application establishment data, 2025.
Other plans filed by this employer
How this plan compares
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Renewal calendar
17 other employer plans in Maine are October 1 renewals (policy year ends September).
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