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Filing

Automatic Data Processing Employee Welfare Benefit

AUTOMATIC DATA PROECESSING INC • EIN 22-1467904 • Plan year 2008

Company ProfileSource Archive
Filing Insights

Participants

Up

31,831 → 31,944

113 • 0.35%

Assets

Down

$49,349,452 → $44,011,502

-$5,337,950 • -10.82%

Investment Management Fee

0.00%

$0

Admin expenses $13,120,542 • Total expenses $262,697,001

Filing Details

Context
Net investment result
$-5,337,950

Status Flags

Fidelity bond in place

Yes

Limited-scope audit performed

Not reported

Contributions transmitted on time

No

Participant loans in default

No

Leases in default

No

Reportable party-in-interest issues

No

Loss discovered during year

No

Assets with undetermined value

No

Non-cash contributions

No

Assets held for investment

Yes

5% transactions reported

Yes

All plan assets distributed

No

Benefits paid when due

Not reported

Plan blackout period

Not reported

Plan termination resolution adopted

No

Counterparties
ProviderServicesLocationDirect CompensationRelated
J.H. COHN LLPEIN 22-1478099Accountant--Jh Cohn LLP

Company Timeline

This filing is highlighted inside the broader sponsor history.

Year / FilingFilingsParticipantsAssetsContributionsContrib./Participant
2024334,516$9,188,170,399$946,809,049$27,431iApproximate average salary by contribution assumption: employee only about $685,775 at 4% or $457,184 at 6%; with 50% employer match about $457,184 at 4% or $304,789 at 6%; with 100% employer match about $342,888 at 4% or $228,592 at 6%.
Automatic Data Processing Retirement Savings Plan-34,516$7,263,696,267$545,367,502$15,800iApproximate average salary by contribution assumption: employee only about $395,011 at 4% or $263,340 at 6%; with 50% employer match about $263,340 at 4% or $175,560 at 6%; with 100% employer match about $197,505 at 4% or $131,670 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-9,395$1,751,944,267--
Automatic Data Processing Employee Welfare Benefit-34,063$172,529,865$401,441,547$11,785iApproximate average salary by contribution assumption: employee only about $294,632 at 4% or $196,421 at 6%; with 50% employer match about $196,421 at 4% or $130,947 at 6%; with 100% employer match about $147,316 at 4% or $98,211 at 6%.
2023334,557$8,248,780,194$899,837,123$26,039iApproximate average salary by contribution assumption: employee only about $650,980 at 4% or $433,987 at 6%; with 50% employer match about $433,987 at 4% or $289,325 at 6%; with 100% employer match about $325,490 at 4% or $216,993 at 6%.
Automatic Data Processing Retirement Savings Plan-34,557$6,329,049,479$523,574,558$15,151iApproximate average salary by contribution assumption: employee only about $378,776 at 4% or $252,517 at 6%; with 50% employer match about $252,517 at 4% or $168,345 at 6%; with 100% employer match about $189,388 at 4% or $126,259 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-10,049$1,743,547,182--
Automatic Data Processing Employee Welfare Benefit-34,539$176,183,533$376,262,565$10,894iApproximate average salary by contribution assumption: employee only about $272,346 at 4% or $181,564 at 6%; with 50% employer match about $181,564 at 4% or $121,043 at 6%; with 100% employer match about $136,173 at 4% or $90,782 at 6%.
2022333,407$7,016,295,219$873,097,090$26,135iApproximate average salary by contribution assumption: employee only about $653,379 at 4% or $435,586 at 6%; with 50% employer match about $435,586 at 4% or $290,391 at 6%; with 100% employer match about $326,689 at 4% or $217,793 at 6%.
Automatic Data Processing Retirement Savings Plan-33,407$5,250,023,503$480,117,896$14,372iApproximate average salary by contribution assumption: employee only about $359,294 at 4% or $239,530 at 6%; with 50% employer match about $239,530 at 4% or $159,686 at 6%; with 100% employer match about $179,647 at 4% or $119,765 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-10,502$1,591,257,729--
Automatic Data Processing Employee Welfare Benefit-33,407$175,013,987$392,979,194$11,763iApproximate average salary by contribution assumption: employee only about $294,084 at 4% or $196,056 at 6%; with 50% employer match about $196,056 at 4% or $130,704 at 6%; with 100% employer match about $147,042 at 4% or $98,028 at 6%.
2021331,257$8,421,768,076$796,139,285$25,471iApproximate average salary by contribution assumption: employee only about $636,769 at 4% or $424,513 at 6%; with 50% employer match about $424,513 at 4% or $283,008 at 6%; with 100% employer match about $318,384 at 4% or $212,256 at 6%.
Automatic Data Processing Retirement Savings Plan-31,257$6,122,934,941$436,819,764$13,975iApproximate average salary by contribution assumption: employee only about $349,378 at 4% or $232,918 at 6%; with 50% employer match about $232,918 at 4% or $155,279 at 6%; with 100% employer match about $174,689 at 4% or $116,459 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-11,269$2,146,621,225--
Automatic Data Processing Employee Welfare Benefit-31,113$152,211,910$359,319,521$11,549iApproximate average salary by contribution assumption: employee only about $288,721 at 4% or $192,481 at 6%; with 50% employer match about $192,481 at 4% or $128,321 at 6%; with 100% employer match about $144,361 at 4% or $96,240 at 6%.
2020330,924$7,448,315,919$727,132,761$23,514iApproximate average salary by contribution assumption: employee only about $587,839 at 4% or $391,892 at 6%; with 50% employer match about $391,892 at 4% or $261,262 at 6%; with 100% employer match about $293,919 at 4% or $195,946 at 6%.
Automatic Data Processing Retirement Savings Plan-30,887$5,275,995,623$382,244,397$12,376iApproximate average salary by contribution assumption: employee only about $309,389 at 4% or $206,260 at 6%; with 50% employer match about $206,260 at 4% or $137,506 at 6%; with 100% employer match about $154,695 at 4% or $103,130 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-12,324$2,046,395,397--
Automatic Data Processing Employee Welfare Benefit-30,924$125,924,899$344,888,364$11,153iApproximate average salary by contribution assumption: employee only about $278,819 at 4% or $185,880 at 6%; with 50% employer match about $185,880 at 4% or $123,920 at 6%; with 100% employer match about $139,410 at 4% or $92,940 at 6%.
2019332,235$6,486,300,186$690,657,497$21,426iApproximate average salary by contribution assumption: employee only about $535,643 at 4% or $357,095 at 6%; with 50% employer match about $357,095 at 4% or $238,063 at 6%; with 100% employer match about $267,821 at 4% or $178,548 at 6%.
Automatic Data Processing Retirement Savings Plan-32,235$4,562,570,022$368,063,534$11,418iApproximate average salary by contribution assumption: employee only about $285,453 at 4% or $190,302 at 6%; with 50% employer match about $190,302 at 4% or $126,868 at 6%; with 100% employer match about $142,727 at 4% or $95,151 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-13,297$1,829,291,675--
Automatic Data Processing Employee Welfare Benefit-32,223$94,438,489$322,593,963$10,011iApproximate average salary by contribution assumption: employee only about $250,282 at 4% or $166,855 at 6%; with 50% employer match about $166,855 at 4% or $111,237 at 6%; with 100% employer match about $125,141 at 4% or $83,427 at 6%.
2018332,065$5,593,248,171$711,418,328$22,187iApproximate average salary by contribution assumption: employee only about $554,669 at 4% or $369,779 at 6%; with 50% employer match about $369,779 at 4% or $246,520 at 6%; with 100% employer match about $277,334 at 4% or $184,890 at 6%.
Automatic Data Processing Retirement Savings Plan-32,065$3,834,086,240$366,774,637$11,438iApproximate average salary by contribution assumption: employee only about $285,962 at 4% or $190,641 at 6%; with 50% employer match about $190,641 at 4% or $127,094 at 6%; with 100% employer match about $142,981 at 4% or $95,321 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-14,998$1,658,244,023--
Automatic Data Processing Employee Welfare Benefit-31,910$100,917,908$344,643,691$10,800iApproximate average salary by contribution assumption: employee only about $270,012 at 4% or $180,008 at 6%; with 50% employer match about $180,008 at 4% or $120,005 at 6%; with 100% employer match about $135,006 at 4% or $90,004 at 6%.
2017333,347$6,581,592,567$710,630,991$21,310iApproximate average salary by contribution assumption: employee only about $532,755 at 4% or $355,170 at 6%; with 50% employer match about $355,170 at 4% or $236,780 at 6%; with 100% employer match about $266,377 at 4% or $177,585 at 6%.
Automatic Data Processing Retirement Savings Plan-33,347$4,385,385,475$342,945,026$10,284iApproximate average salary by contribution assumption: employee only about $257,103 at 4% or $171,402 at 6%; with 50% employer match about $171,402 at 4% or $114,268 at 6%; with 100% employer match about $128,552 at 4% or $85,701 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-18,815$2,116,665,189--
Automatic Data Processing Employee Welfare Benefit-33,327$79,541,903$367,685,965$11,033iApproximate average salary by contribution assumption: employee only about $275,817 at 4% or $183,878 at 6%; with 50% employer match about $183,878 at 4% or $122,585 at 6%; with 100% employer match about $137,908 at 4% or $91,939 at 6%.
2016331,952$5,631,245,859$639,272,891$20,007iApproximate average salary by contribution assumption: employee only about $500,182 at 4% or $333,455 at 6%; with 50% employer match about $333,455 at 4% or $222,303 at 6%; with 100% employer match about $250,091 at 4% or $166,727 at 6%.
Automatic Data Processing Retirement Savings Plan-31,952$3,732,822,452$315,452,222$9,873iApproximate average salary by contribution assumption: employee only about $246,817 at 4% or $164,545 at 6%; with 50% employer match about $164,545 at 4% or $109,697 at 6%; with 100% employer match about $123,409 at 4% or $82,272 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-21,467$1,841,747,390--
Automatic Data Processing Employee Welfare Benefit-31,768$56,676,017$323,820,669$10,193iApproximate average salary by contribution assumption: employee only about $254,832 at 4% or $169,888 at 6%; with 50% employer match about $169,888 at 4% or $113,259 at 6%; with 100% employer match about $127,416 at 4% or $84,944 at 6%.
2015330,106$5,265,993,378$611,271,463$20,304iApproximate average salary by contribution assumption: employee only about $507,599 at 4% or $338,400 at 6%; with 50% employer match about $338,400 at 4% or $225,600 at 6%; with 100% employer match about $253,800 at 4% or $169,200 at 6%.
Automatic Data Processing Retirement Savings Plan-30,106$3,408,986,491$300,214,214$9,972iApproximate average salary by contribution assumption: employee only about $249,298 at 4% or $166,198 at 6%; with 50% employer match about $166,198 at 4% or $110,799 at 6%; with 100% employer match about $124,649 at 4% or $83,099 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-25,740$1,802,979,137--
Automatic Data Processing Employee Welfare Benefit-29,932$54,027,750$311,057,249$10,392iApproximate average salary by contribution assumption: employee only about $259,803 at 4% or $173,202 at 6%; with 50% employer match about $173,202 at 4% or $115,468 at 6%; with 100% employer match about $129,902 at 4% or $86,601 at 6%.
2014335,998$5,327,539,614$651,124,900$18,088iApproximate average salary by contribution assumption: employee only about $452,195 at 4% or $301,463 at 6%; with 50% employer match about $301,463 at 4% or $200,976 at 6%; with 100% employer match about $226,098 at 4% or $150,732 at 6%.
Automatic Data Processing Retirement Savings Plan-35,998$3,378,994,809$306,626,764$8,518iApproximate average salary by contribution assumption: employee only about $212,947 at 4% or $141,965 at 6%; with 50% employer match about $141,965 at 4% or $94,643 at 6%; with 100% employer match about $106,474 at 4% or $70,982 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-30,006$1,889,401,993--
Automatic Data Processing Employee Welfare Benefit-29,497$59,142,812$344,498,136$11,679iApproximate average salary by contribution assumption: employee only about $291,977 at 4% or $194,652 at 6%; with 50% employer match about $194,652 at 4% or $129,768 at 6%; with 100% employer match about $145,989 at 4% or $97,326 at 6%.
2013336,107$5,393,108,926$638,025,430$17,670iApproximate average salary by contribution assumption: employee only about $441,760 at 4% or $294,507 at 6%; with 50% employer match about $294,507 at 4% or $196,338 at 6%; with 100% employer match about $220,880 at 4% or $147,253 at 6%.
Automatic Data Processing Retirement Savings Plan-36,107$3,552,315,383$291,191,575$8,065iApproximate average salary by contribution assumption: employee only about $201,617 at 4% or $134,411 at 6%; with 50% employer match about $134,411 at 4% or $89,608 at 6%; with 100% employer match about $100,809 at 4% or $67,206 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-29,992$1,780,193,456--
Automatic Data Processing Employee Welfare Benefit-35,976$60,600,087$346,833,855$9,641iApproximate average salary by contribution assumption: employee only about $241,018 at 4% or $160,678 at 6%; with 50% employer match about $160,678 at 4% or $107,119 at 6%; with 100% employer match about $120,509 at 4% or $80,339 at 6%.
2012335,812$4,569,104,049$681,820,330$19,039iApproximate average salary by contribution assumption: employee only about $475,972 at 4% or $317,315 at 6%; with 50% employer match about $317,315 at 4% or $211,543 at 6%; with 100% employer match about $237,986 at 4% or $158,657 at 6%.
Automatic Data Processing Retirement Savings Plan-35,812$2,818,776,418$271,363,857$7,577iApproximate average salary by contribution assumption: employee only about $189,436 at 4% or $126,291 at 6%; with 50% employer match about $126,291 at 4% or $84,194 at 6%; with 100% employer match about $94,718 at 4% or $63,145 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-29,047$1,681,611,953$75,000,000$2,582iApproximate average salary by contribution assumption: employee only about $64,551 at 4% or $43,034 at 6%; with 50% employer match about $43,034 at 4% or $28,689 at 6%; with 100% employer match about $32,275 at 4% or $21,517 at 6%.
Automatic Data Processing Employee Welfare Benefit-31,733$68,715,678$335,456,473$10,571iApproximate average salary by contribution assumption: employee only about $264,280 at 4% or $176,187 at 6%; with 50% employer match about $176,187 at 4% or $117,458 at 6%; with 100% employer match about $132,140 at 4% or $88,093 at 6%.
2011334,226$3,994,837,019$692,291,495$20,227iApproximate average salary by contribution assumption: employee only about $505,677 at 4% or $337,118 at 6%; with 50% employer match about $337,118 at 4% or $224,745 at 6%; with 100% employer match about $252,838 at 4% or $168,559 at 6%.
Automatic Data Processing Retirement Savings Plan-34,226$2,465,834,853$239,792,189$7,006iApproximate average salary by contribution assumption: employee only about $175,154 at 4% or $116,769 at 6%; with 50% employer match about $116,769 at 4% or $77,846 at 6%; with 100% employer match about $87,577 at 4% or $58,385 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-27,945$1,458,490,950$125,000,000$4,473iApproximate average salary by contribution assumption: employee only about $111,827 at 4% or $74,551 at 6%; with 50% employer match about $74,551 at 4% or $49,701 at 6%; with 100% employer match about $55,913 at 4% or $37,276 at 6%.
Automatic Data Processing Employee Welfare Benefit-28,769$70,511,216$327,499,306$11,384iApproximate average salary by contribution assumption: employee only about $284,594 at 4% or $189,729 at 6%; with 50% employer match about $189,729 at 4% or $126,486 at 6%; with 100% employer match about $142,297 at 4% or $94,865 at 6%.
2010332,605$3,623,768,942$580,138,607$17,793iApproximate average salary by contribution assumption: employee only about $444,823 at 4% or $296,549 at 6%; with 50% employer match about $296,549 at 4% or $197,699 at 6%; with 100% employer match about $222,412 at 4% or $148,274 at 6%.
Automatic Data Processing Retirement Savings Plan-32,605$2,293,337,115$210,761,978$6,464iApproximate average salary by contribution assumption: employee only about $161,602 at 4% or $107,735 at 6%; with 50% employer match about $107,735 at 4% or $71,823 at 6%; with 100% employer match about $80,801 at 4% or $53,867 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-26,829$1,270,577,076$75,000,000$2,795iApproximate average salary by contribution assumption: employee only about $69,887 at 4% or $46,591 at 6%; with 50% employer match about $46,591 at 4% or $31,061 at 6%; with 100% employer match about $34,944 at 4% or $23,296 at 6%.
Automatic Data Processing Employee Welfare Benefit-31,343$59,854,751$294,376,629$9,392iApproximate average salary by contribution assumption: employee only about $234,803 at 4% or $156,535 at 6%; with 50% employer match about $156,535 at 4% or $104,357 at 6%; with 100% employer match about $117,401 at 4% or $78,268 at 6%.
2009431,495$3,081,704,633$645,201,507$20,486iApproximate average salary by contribution assumption: employee only about $512,146 at 4% or $341,431 at 6%; with 50% employer match about $341,431 at 4% or $227,620 at 6%; with 100% employer match about $256,073 at 4% or $170,715 at 6%.
Automatic Data Processing Retirement Savings Plan-31,495$1,934,768,054$200,526,637$6,367iApproximate average salary by contribution assumption: employee only about $159,173 at 4% or $106,116 at 6%; with 50% employer match about $106,116 at 4% or $70,744 at 6%; with 100% employer match about $79,587 at 4% or $53,058 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-26,990$1,087,225,895$150,000,000$5,558iApproximate average salary by contribution assumption: employee only about $138,940 at 4% or $92,627 at 6%; with 50% employer match about $92,627 at 4% or $61,751 at 6%; with 100% employer match about $69,470 at 4% or $46,313 at 6%.
Automatic Data Processing Employee Welfare Benefit-29,137$59,710,684$294,674,870$10,113iApproximate average salary by contribution assumption: employee only about $252,836 at 4% or $168,557 at 6%; with 50% employer match about $168,557 at 4% or $112,371 at 6%; with 100% employer match about $126,418 at 4% or $84,279 at 6%.
Adp Business Travel Accidental Death & Dismemberme-0---
2008446,505$2,473,177,146$565,230,011$12,154iApproximate average salary by contribution assumption: employee only about $303,854 at 4% or $202,570 at 6%; with 50% employer match about $202,570 at 4% or $135,046 at 6%; with 100% employer match about $151,927 at 4% or $101,285 at 6%.
Automatic Data Processing Retirement Savings Plan-34,536$1,588,962,016$208,458,107$6,036iApproximate average salary by contribution assumption: employee only about $150,899 at 4% or $100,599 at 6%; with 50% employer match about $100,599 at 4% or $67,066 at 6%; with 100% employer match about $75,450 at 4% or $50,300 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-27,027$840,203,628$100,000,000$3,700iApproximate average salary by contribution assumption: employee only about $92,500 at 4% or $61,667 at 6%; with 50% employer match about $61,667 at 4% or $41,111 at 6%; with 100% employer match about $46,250 at 4% or $30,833 at 6%.
Automatic Data Processing Employee Welfare BenefitCurrent31,944$44,011,502$256,771,904$8,038iApproximate average salary by contribution assumption: employee only about $200,955 at 4% or $133,970 at 6%; with 50% employer match about $133,970 at 4% or $89,313 at 6%; with 100% employer match about $100,477 at 4% or $66,985 at 6%.
Adp Business Travel Accidental Death & Dismemberme-46,505---
2007446,000$3,002,800,525$488,278,934$10,615iApproximate average salary by contribution assumption: employee only about $265,369 at 4% or $176,913 at 6%; with 50% employer match about $176,913 at 4% or $117,942 at 6%; with 100% employer match about $132,684 at 4% or $88,456 at 6%.
Automatic Data Processing Retirement Savings Plan-34,350$1,990,291,854$203,201,508$5,916iApproximate average salary by contribution assumption: employee only about $147,890 at 4% or $98,594 at 6%; with 50% employer match about $98,594 at 4% or $65,729 at 6%; with 100% employer match about $73,945 at 4% or $49,297 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-25,661$963,159,219$50,000,000$1,948iApproximate average salary by contribution assumption: employee only about $48,712 at 4% or $32,475 at 6%; with 50% employer match about $32,475 at 4% or $21,650 at 6%; with 100% employer match about $24,356 at 4% or $16,237 at 6%.
Automatic Data Processing Employee Welfare Benefit-31,344$49,349,452$235,077,426$7,500iApproximate average salary by contribution assumption: employee only about $187,498 at 4% or $124,999 at 6%; with 50% employer match about $124,999 at 4% or $83,332 at 6%; with 100% employer match about $93,749 at 4% or $62,499 at 6%.
Adp Business Travel Accidental Death & Dismemberme-46,000---
2006546,000$2,876,830,682$469,460,225$10,206iApproximate average salary by contribution assumption: employee only about $255,141 at 4% or $170,094 at 6%; with 50% employer match about $170,094 at 4% or $113,396 at 6%; with 100% employer match about $127,571 at 4% or $85,047 at 6%.
Automatic Data Processing Retirement Savings Plan-34,428$1,952,351,957$195,929,649$5,691iApproximate average salary by contribution assumption: employee only about $142,275 at 4% or $94,850 at 6%; with 50% employer match about $94,850 at 4% or $63,233 at 6%; with 100% employer match about $71,137 at 4% or $47,425 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-28,355$864,355,725$20,000,000$705iApproximate average salary by contribution assumption: employee only about $17,634 at 4% or $11,756 at 6%; with 50% employer match about $11,756 at 4% or $7,837 at 6%; with 100% employer match about $8,817 at 4% or $5,878 at 6%.
Automatic Data Processing Employee Welfare Benefit-33,708$60,123,000$253,530,576$7,521iApproximate average salary by contribution assumption: employee only about $188,034 at 4% or $125,356 at 6%; with 50% employer match about $125,356 at 4% or $83,571 at 6%; with 100% employer match about $94,017 at 4% or $62,678 at 6%.
Automatic Data Processing Employee Welfare Benefit-33,708---
Adp Business Travel Accidental Death & Dismemberme-46,000---
2005546,000$107,797,512$427,726,257$9,298iApproximate average salary by contribution assumption: employee only about $232,460 at 4% or $154,973 at 6%; with 50% employer match about $154,973 at 4% or $103,316 at 6%; with 100% employer match about $116,230 at 4% or $77,487 at 6%.
Automatic Data Processing Employee Welfare Benefit-31,600$54,289,961$231,623,108$7,330iApproximate average salary by contribution assumption: employee only about $183,246 at 4% or $122,164 at 6%; with 50% employer match about $122,164 at 4% or $81,443 at 6%; with 100% employer match about $91,623 at 4% or $61,082 at 6%.
Automatic Data Processing Employee Welfare Benefit-31,600$53,507,551$196,103,149$6,206iApproximate average salary by contribution assumption: employee only about $155,145 at 4% or $103,430 at 6%; with 50% employer match about $103,430 at 4% or $68,953 at 6%; with 100% employer match about $77,572 at 4% or $51,715 at 6%.
Adp Business Travel Accidental Death & Dismemberme-46,000---
Automatic Data Processing Retirement Savings Plan-33,638---
Automatic Data Processing Inc Pension Retirement Plan-26,269---
2004544,000$2,294,089,247$353,087,691$8,025iApproximate average salary by contribution assumption: employee only about $200,618 at 4% or $133,745 at 6%; with 50% employer match about $133,745 at 4% or $89,164 at 6%; with 100% employer match about $100,309 at 4% or $66,873 at 6%.
Automatic Data Processing Retirement Savings Plan-33,418$1,518,560,443$166,259,448$4,975iApproximate average salary by contribution assumption: employee only about $124,379 at 4% or $82,919 at 6%; with 50% employer match about $82,919 at 4% or $55,279 at 6%; with 100% employer match about $62,189 at 4% or $41,460 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-25,121$731,484,134$42,417,090$1,689iApproximate average salary by contribution assumption: employee only about $42,213 at 4% or $28,142 at 6%; with 50% employer match about $28,142 at 4% or $18,761 at 6%; with 100% employer match about $21,106 at 4% or $14,071 at 6%.
Automatic Data Processing Employee Welfare Benefit-30,727$44,044,670$144,411,153$4,700iApproximate average salary by contribution assumption: employee only about $117,495 at 4% or $78,330 at 6%; with 50% employer match about $78,330 at 4% or $52,220 at 6%; with 100% employer match about $58,748 at 4% or $39,165 at 6%.
Adp Business Travel Accidental Death & Dismemberme-44,000---
Automatic Data Processing Employee Welfare Benefit-30,727---
2003531,739$1,986,287,354$351,152,640$11,064iApproximate average salary by contribution assumption: employee only about $276,594 at 4% or $184,396 at 6%; with 50% employer match about $184,396 at 4% or $122,931 at 6%; with 100% employer match about $138,297 at 4% or $92,198 at 6%.
Automatic Data Processing Retirement Savings Plan-31,739$1,293,741,154$141,132,646$4,447iApproximate average salary by contribution assumption: employee only about $111,167 at 4% or $74,111 at 6%; with 50% employer match about $74,111 at 4% or $49,407 at 6%; with 100% employer match about $55,583 at 4% or $37,056 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-24,051$636,122,664$86,253,393$3,586iApproximate average salary by contribution assumption: employee only about $89,657 at 4% or $59,771 at 6%; with 50% employer match about $59,771 at 4% or $39,847 at 6%; with 100% employer match about $44,828 at 4% or $29,886 at 6%.
Automatic Data Processing Employee Welfare Benefit-30,759$56,423,536$123,766,601$4,024iApproximate average salary by contribution assumption: employee only about $100,594 at 4% or $67,063 at 6%; with 50% employer match about $67,063 at 4% or $44,708 at 6%; with 100% employer match about $50,297 at 4% or $33,531 at 6%.
Adp Business Travel Accidental Death & Dismemberme-30,325---
Automatic Data Processing Retirement Savings Plan-31,739---
2002531,271$457,898,968$63,256,593$2,023iApproximate average salary by contribution assumption: employee only about $50,571 at 4% or $33,714 at 6%; with 50% employer match about $33,714 at 4% or $22,476 at 6%; with 100% employer match about $25,286 at 4% or $16,857 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-24,624$457,898,968$63,256,593$2,569iApproximate average salary by contribution assumption: employee only about $64,222 at 4% or $42,815 at 6%; with 50% employer match about $42,815 at 4% or $28,543 at 6%; with 100% employer match about $32,111 at 4% or $21,407 at 6%.
Adp Business Travel Accidental Death & Dismemberme-28,448---
Automatic Data Processing Employee Welfare Benefit-29,475---
SAVINGS PLAN FOR FORMER EMPLOYEES OF VINCAM HUMAN RESOURCES INC-0---
Automatic Data Processing Retirement Savings Plan-31,271---
2001740,000$1,710,652,562$290,911,860$7,273iApproximate average salary by contribution assumption: employee only about $181,820 at 4% or $121,213 at 6%; with 50% employer match about $121,213 at 4% or $80,809 at 6%; with 100% employer match about $90,910 at 4% or $60,607 at 6%.
Automatic Data Processing Retirement Savings Plan-31,597$1,205,995,201$137,850,899$4,363iApproximate average salary by contribution assumption: employee only about $109,070 at 4% or $72,713 at 6%; with 50% employer match about $72,713 at 4% or $48,475 at 6%; with 100% employer match about $54,535 at 4% or $36,357 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-23,424$461,868,990$31,444,299$1,342iApproximate average salary by contribution assumption: employee only about $33,560 at 4% or $22,373 at 6%; with 50% employer match about $22,373 at 4% or $14,916 at 6%; with 100% employer match about $16,780 at 4% or $11,187 at 6%.
Automatic Data Processing Employee Welfare Benefit-30,010$38,050,497$120,139,138$4,003iApproximate average salary by contribution assumption: employee only about $100,083 at 4% or $66,722 at 6%; with 50% employer match about $66,722 at 4% or $44,481 at 6%; with 100% employer match about $50,041 at 4% or $33,361 at 6%.
SAVINGS PLAN FOR FORMER EMPLOYEES OF VINCAM HUMAN RESOURCES INC-207$4,737,874$1,477,524$7,138iApproximate average salary by contribution assumption: employee only about $178,445 at 4% or $118,963 at 6%; with 50% employer match about $118,963 at 4% or $79,309 at 6%; with 100% employer match about $89,222 at 4% or $59,482 at 6%.
AUTO DATA PROCESSING - HEALTH CARE PLUS SPENDING-0---
Adp Employee Assistance Program-40,000---
Adp Business Travel Accidental Death & Dismemberme-27,228---
2000641,000$493,283,229$114,203,273$2,785iApproximate average salary by contribution assumption: employee only about $69,636 at 4% or $46,424 at 6%; with 50% employer match about $46,424 at 4% or $30,949 at 6%; with 100% employer match about $34,818 at 4% or $23,212 at 6%.
Automatic Data Processing Inc Pension Retirement Plan-21,865$469,018,064$34,679,244$1,586iApproximate average salary by contribution assumption: employee only about $39,652 at 4% or $26,434 at 6%; with 50% employer match about $26,434 at 4% or $17,623 at 6%; with 100% employer match about $19,826 at 4% or $13,217 at 6%.
Automatic Data Processing Employee Welfare Benefit-29,823$24,265,165$79,524,029$2,667iApproximate average salary by contribution assumption: employee only about $66,663 at 4% or $44,442 at 6%; with 50% employer match about $44,442 at 4% or $29,628 at 6%; with 100% employer match about $33,332 at 4% or $22,221 at 6%.
Adp Business Travel Accidental Death & Dismemberme-26,051---
Adp Business Travel Accidental Death & Dismemberme-26,051---
Adp Employee Assistance Program-41,000---
Automatic Data Processing Retirement Savings Plan-32,626---
1999440,000$1,185,512,112$182,077,074$4,552iApproximate average salary by contribution assumption: employee only about $113,798 at 4% or $75,865 at 6%; with 50% employer match about $75,865 at 4% or $50,577 at 6%; with 100% employer match about $56,899 at 4% or $37,933 at 6%.
Automatic Data Processing Retirement Savings Plan-30,301$1,152,834,855$112,518,675$3,713iApproximate average salary by contribution assumption: employee only about $92,834 at 4% or $61,889 at 6%; with 50% employer match about $61,889 at 4% or $41,260 at 6%; with 100% employer match about $46,417 at 4% or $30,945 at 6%.
Automatic Data Processing Employee Welfare Benefit-22,366$32,677,257$69,558,399$3,110iApproximate average salary by contribution assumption: employee only about $77,750 at 4% or $51,833 at 6%; with 50% employer match about $51,833 at 4% or $34,556 at 6%; with 100% employer match about $38,875 at 4% or $25,917 at 6%.
Adp Business Travel Accidental Death & Dismemberme-26,278---
Adp Employee Assistance Program-40,000---
Schedule Details

Schedule A

Row 1
Filing Id
84037014197020
Form Id
100971019
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020025
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 2
Filing Id
84037014197020
Form Id
100970997
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020003
Ins Broker 01 Name
MARSH USA
Ins Broker 01 Street Addr
1166 AVENUE OF THE AMERICAS
Ins Broker 01 City
NEW YORK
Ins Broker 01 State
NY
Ins Broker 01 ZIP Code
10036
Ins Broker Comm Pd 01 Amount
$55,849
Ins Broker Fees Pd 01 Amount
$0
Ins Broker 01 Code
3
Row 3
Filing Id
84037014197020
Form Id
100971000
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020006
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 4
Filing Id
84037014197020
Form Id
100971001
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020007
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 5
Filing Id
84037014197020
Form Id
100971004
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020010
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 6
Filing Id
84037014197020
Form Id
100971009
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020015
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 7
Filing Id
84037014197020
Form Id
100971006
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020012
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 8
Filing Id
84037014197020
Form Id
100971011
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020017
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 9
Filing Id
84037014197020
Form Id
100971026
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020032
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 10
Filing Id
84037014197020
Form Id
100971010
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020016
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 11
Filing Id
84037014197020
Form Id
100971016
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020022
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 12
Filing Id
84037014197020
Form Id
100971018
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020024
Ins Broker 01 Name
WILLIAM M MERCER INC
Ins Broker 01 Street Addr
1166 AVENUE OF THE AMERICAS
Ins Broker 01 City
NEW YORK
Ins Broker 01 State
NY
Ins Broker 01 ZIP Code
10036
Ins Broker Comm Pd 01 Amount
$4,788
Ins Broker Fees Pd 01 Amount
$0
Ins Broker 01 Code
3
Row 13
Filing Id
84037014197020
Form Id
100971014
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020020
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 14
Filing Id
84037014197020
Form Id
100971015
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020021
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 15
Filing Id
84037014197020
Form Id
100971025
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020031
Ins Broker 01 Name
MERCER HEALTH & BENEFITS
Ins Broker 01 Street Addr
4565 PAYSPHERE CIRCLE
Ins Broker 01 City
CHICAGO
Ins Broker 01 State
IL
Ins Broker 01 ZIP Code
606740045
Ins Broker Comm Pd 01 Amount
$39,996
Ins Broker Fees Pd 01 Amount
$0
Ins Broker 01 Code
3
Row 16
Filing Id
84037014197020
Form Id
100971012
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020018
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 17
Filing Id
84037014197020
Form Id
100971023
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020029
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 18
Filing Id
84037014197020
Form Id
100970999
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020005
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 19
Filing Id
84037014197020
Form Id
100971024
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020030
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 20
Filing Id
84037014197020
Form Id
100971017
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020023
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 21
Filing Id
84037014197020
Form Id
100971003
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020009
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 22
Filing Id
84037014197020
Form Id
100971028
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020034
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 23
Filing Id
84037014197020
Form Id
100971027
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020033
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 24
Filing Id
84037014197020
Form Id
100971022
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020028
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 25
Filing Id
84037014197020
Form Id
100970996
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020002
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 26
Filing Id
84037014197020
Form Id
100971013
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020019
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 27
Filing Id
84037014197020
Form Id
100971020
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020026
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 28
Filing Id
84037014197020
Form Id
100971005
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020011
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 29
Filing Id
84037014197020
Form Id
100971021
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020027
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 30
Filing Id
84037014197020
Form Id
100971008
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020014
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 31
Filing Id
84037014197020
Form Id
100971007
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020013
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 32
Filing Id
84037014197020
Form Id
100971002
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020008
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 33
Filing Id
84037014197020
Form Id
100970998
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020004
Ins Broker 01 Name
MARSH USA
Ins Broker 01 Street Addr
1166 AVENUE OF THE AMERICAS
Ins Broker 01 City
NEW YORK
Ins Broker 01 State
NY
Ins Broker 01 ZIP Code
10036
Ins Broker Comm Pd 01 Amount
$196,086
Ins Broker Fees Pd 01 Amount
$0
Ins Broker 01 Code
3
Row 34
Ins Carrier Name: PACIFICARE OF ARIZONA
Filing Id
84037014197020
Form Id
100971020
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
PACIFICARE OF ARIZONA
Ins Carrier EIN
94-3267522
Ins Carrier Naic Code
95617
Ins Contract Num
CV201
Ins Prsn Covered End of year Count
18
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
HJ
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$157,861
Wlfr Acquis Cost Amount
$0
Row 35
Ins Carrier Name: KAISER FOUNDATION HEALTH PLANS, INC.
Filing Id
84037014197020
Form Id
100971016
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
KAISER FOUNDATION HEALTH PLANS, INC.
Ins Carrier EIN
94-1340523
Ins Carrier Naic Code
00000
Ins Contract Num
20971
Ins Prsn Covered End of year Count
965
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AJ
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$2,737,923
Wlfr Acquis Cost Amount
$0
Row 36
Ins Carrier Name: HORIZON HEALTHCARE OF NEW JERSEY, INC.
Filing Id
84037014197020
Form Id
100971008
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
HORIZON HEALTHCARE OF NEW JERSEY, INC.
Ins Carrier EIN
22-2651245
Ins Carrier Naic Code
95529
Ins Contract Num
85006
Ins Prsn Covered End of year Count
43
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
J
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$428,378
Wlfr Acquis Cost Amount
$0
Row 37
Ins Carrier Name: RELIASTAR LIFE INSURANCE COMPANY
Filing Id
84037014197020
Form Id
100971025
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
RELIASTAR LIFE INSURANCE COMPANY
Ins Carrier EIN
41-0451140
Ins Carrier Naic Code
67015
Ins Contract Num
64841-8
Ins Prsn Covered End of year Count
25,419
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$39,996
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
M
Wlfr Type Bnft Oth Text
INDIVIDUAL EXCESS RISK
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$1,699,662
Wlfr Acquis Cost Amount
$0
Row 38
Ins Carrier Name: MVP HEALTH CARE
Filing Id
84037014197020
Form Id
100971018
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
MVP HEALTH CARE
Ins Carrier EIN
14-1640868
Ins Carrier Naic Code
95521
Ins Contract Num
212164
Ins Prsn Covered End of year Count
68
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$4,788
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
A
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$225,459
Wlfr Acquis Cost Amount
$0
Row 39
Ins Carrier Name: BLUE CROSS BLUE SHIELD OF ILLINOIS
Filing Id
84037014197020
Form Id
100971002
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
BLUE CROSS BLUE SHIELD OF ILLINOIS
Ins Carrier EIN
36-1236610
Ins Carrier Naic Code
70670
Ins Contract Num
H06201
Ins Prsn Covered End of year Count
251
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AJ
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$870,993
Wlfr Acquis Cost Amount
$0
Row 40
Ins Carrier Name: TUFTS ASSOCIATED HEALTH MAINTENANCE ORG. INC.
Filing Id
84037014197020
Form Id
100971027
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
TUFTS ASSOCIATED HEALTH MAINTENANCE ORG. INC.
Ins Carrier EIN
04-2674079
Ins Carrier Naic Code
95688
Ins Contract Num
76960000
Ins Prsn Covered End of year Count
147
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
A
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$1,639,043
Wlfr Acquis Cost Amount
$0
Row 41
Ins Carrier Name: KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Filing Id
84037014197020
Form Id
100971012
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
KAISER FOUNDATION HEALTH PLAN OF GEORGIA, INC.
Ins Carrier EIN
58-1592076
Ins Carrier Naic Code
96237
Ins Contract Num
394
Ins Prsn Covered End of year Count
690
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AJ
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$1,613,032
Wlfr Acquis Cost Amount
$0
Row 42
Ins Carrier Name: AIG LIFE
Filing Id
84037014197020
Form Id
100970998
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
AIG LIFE
Ins Carrier EIN
25-1118523
Ins Carrier Naic Code
66842
Ins Contract Num
PAI 8061623
Ins Prsn Covered End of year Count
31,944
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$196,086
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
M
Wlfr Type Bnft Oth Text
AD&D
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$1,307,239
Wlfr Acquis Cost Amount
$0
Row 43
Ins Carrier Name: KAISER FOUNDATION HEALTH PLAN OF COLORADO, INC.
Filing Id
84037014197020
Form Id
100971011
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
KAISER FOUNDATION HEALTH PLAN OF COLORADO, INC.
Ins Carrier EIN
84-0591617
Ins Carrier Naic Code
95669
Ins Contract Num
02497
Ins Prsn Covered End of year Count
113
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AJ
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$264,625
Wlfr Acquis Cost Amount
$0
Row 44
Ins Carrier Name: VISION SERVICE PLAN
Filing Id
84037014197020
Form Id
100971028
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
VISION SERVICE PLAN
Ins Carrier EIN
06-1227840
Ins Carrier Naic Code
36916
Ins Contract Num
12057040
Ins Prsn Covered End of year Count
19,393
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
C
Wlfr Premium Rcvd Amount
$2,998,676
Wlfr Unpaid Due Amount
$273,568
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$3,272,244
Wlfr Claims Paid Amount
$2,901,505
Wlfr Incr Reserve Amount
$48,530
Wlfr Incurred Claim Amount
$2,950,035
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$329,854
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$329,854
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$725,376
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$0
Wlfr Acquis Cost Amount
$0
Row 45
Ins Carrier Name: PRUDENTIAL INSURANCE COMPANY OF AMERICA
Filing Id
84037014197020
Form Id
100971023
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
PRUDENTIAL INSURANCE COMPANY OF AMERICA
Ins Carrier EIN
22-1211670
Ins Carrier Naic Code
68241
Ins Contract Num
17900-1
Ins Prsn Covered End of year Count
32,194
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
D
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$3,112,203
Wlfr Acquis Cost Amount
$0
Row 46
Ins Carrier Name: INDEPENDENT HEALTH
Filing Id
84037014197020
Form Id
100971010
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
INDEPENDENT HEALTH
Ins Carrier EIN
16-1483784
Ins Carrier Naic Code
47034
Ins Contract Num
30944G
Ins Prsn Covered End of year Count
216
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
A
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$740,092
Wlfr Acquis Cost Amount
$0
Row 47
Ins Carrier Name: HIP HEALTH PLANS
Filing Id
84037014197020
Form Id
100971007
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
HIP HEALTH PLANS
Ins Carrier EIN
13-1828429
Ins Carrier Naic Code
55247
Ins Contract Num
100922E000
Ins Prsn Covered End of year Count
24
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
J
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$74,343
Wlfr Acquis Cost Amount
$0
Row 48
Ins Carrier Name: PACIFICARE OF OREGON
Filing Id
84037014197020
Form Id
100971022
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
PACIFICARE OF OREGON
Ins Carrier EIN
93-0938819
Ins Carrier Naic Code
95893
Ins Contract Num
036091
Ins Prsn Covered End of year Count
22
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
J
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$252,434
Wlfr Acquis Cost Amount
$0
Row 49
Ins Carrier Name: KAISER FOUNDATION HEALTH PLAN OF HAWAII
Filing Id
84037014197020
Form Id
100971013
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
KAISER FOUNDATION HEALTH PLAN OF HAWAII
Ins Carrier EIN
94-1340523
Ins Carrier Naic Code
60053
Ins Contract Num
32402/10
Ins Prsn Covered End of year Count
18
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AJ
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$28,432
Wlfr Acquis Cost Amount
$0
Row 50
Ins Carrier Name: PRUDENTIAL INSURANCE COMPANY OF AMERICA
Filing Id
84037014197020
Form Id
100971024
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
PRUDENTIAL INSURANCE COMPANY OF AMERICA
Ins Carrier EIN
22-1211670
Ins Carrier Naic Code
68241
Ins Contract Num
17900-5
Ins Prsn Covered End of year Count
17,955
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
No
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$5,451,308
Wlfr Acquis Cost Amount
$0
Row 51
Ins Carrier Name: HEALTH ALLIANCE PLAN
Filing Id
84037014197020
Form Id
100971006
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
HEALTH ALLIANCE PLAN
Ins Carrier EIN
38-2242827
Ins Carrier Naic Code
95844
Ins Contract Num
1-94111AA
Ins Prsn Covered End of year Count
100
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
J
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$312,013
Wlfr Acquis Cost Amount
$0
Row 52
Ins Carrier Name: EXCELLUS BLUECROSS BLUESHIELD PLAN
Filing Id
84037014197020
Form Id
100971003
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
EXCELLUS BLUECROSS BLUESHIELD PLAN
Ins Carrier EIN
15-0329043
Ins Carrier Naic Code
55107
Ins Contract Num
RLCALL012750001
Ins Prsn Covered End of year Count
27
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AH
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$88,685
Wlfr Acquis Cost Amount
$0
Row 53
Ins Carrier Name: BLUE CARE NETWORK OF MICHIGAN
Filing Id
84037014197020
Form Id
100971000
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
BLUE CARE NETWORK OF MICHIGAN
Ins Carrier EIN
38-2359234
Ins Carrier Naic Code
95610
Ins Contract Num
00115293/0001
Ins Prsn Covered End of year Count
372
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AH
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$1,065,882
Wlfr Acquis Cost Amount
$0
Row 54
Ins Carrier Name: KAISER FOUNDATION HEALTH PLAN OF MID-ATLANTIC STATES, INCC.
Filing Id
84037014197020
Form Id
100971014
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
KAISER FOUNDATION HEALTH PLAN OF MID-ATLANTIC STATES, INCC.
Ins Carrier EIN
52-0954463
Ins Carrier Naic Code
95639
Ins Contract Num
7593
Ins Prsn Covered End of year Count
82
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AJ
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$181,028
Wlfr Acquis Cost Amount
$0
Row 55
Ins Carrier Name: AIG LIFE
Filing Id
84037014197020
Form Id
100970997
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
AIG LIFE
Ins Carrier EIN
25-1118523
Ins Carrier Naic Code
66842
Ins Contract Num
BSC 8061620
Ins Prsn Covered End of year Count
31,944
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$55,849
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
M
Wlfr Type Bnft Oth Text
AD&D
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$372,327
Wlfr Acquis Cost Amount
$0
Row 56
Ins Carrier Name: PACIFICARE OF CALIFORNIA
Filing Id
84037014197020
Form Id
100971021
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
PACIFICARE OF CALIFORNIA
Ins Carrier EIN
95-2931460
Ins Carrier Naic Code
00000
Ins Contract Num
146088
Ins Prsn Covered End of year Count
525
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
J
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$4,035,776
Wlfr Acquis Cost Amount
$0
Row 57
Ins Carrier Name: ALTIUS HEALTH PLAN
Filing Id
84037014197020
Form Id
100970999
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
ALTIUS HEALTH PLAN
Ins Carrier EIN
87-0345631
Ins Carrier Naic Code
95407
Ins Contract Num
6708070000
Ins Prsn Covered End of year Count
340
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
A
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$931,090
Wlfr Acquis Cost Amount
$0
Row 58
Ins Carrier Name: HORIZON HEALTHCARE SERVICES, INC.
Filing Id
84037014197020
Form Id
100971009
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
HORIZON HEALTHCARE SERVICES, INC.
Ins Carrier EIN
22-0999690
Ins Carrier Naic Code
55069
Ins Contract Num
85006
Ins Prsn Covered End of year Count
43
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
H
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$93,345
Wlfr Acquis Cost Amount
$0
Row 59
Ins Carrier Name: OPTIMUM CHOICE, INC.
Filing Id
84037014197020
Form Id
100971019
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
OPTIMUM CHOICE, INC.
Ins Carrier EIN
52-1518174
Ins Carrier Naic Code
96940
Ins Contract Num
51867
Ins Prsn Covered End of year Count
35
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
A
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$299,194
Wlfr Acquis Cost Amount
$0
Row 60
Ins Carrier Name: HAWAII MEDICAL SERVICE ASSOCIATION
Filing Id
84037014197020
Form Id
100971005
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
HAWAII MEDICAL SERVICE ASSOCIATION
Ins Carrier EIN
99-0040115
Ins Carrier Naic Code
49948
Ins Contract Num
94020
Ins Prsn Covered End of year Count
33
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AK
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$95,286
Wlfr Acquis Cost Amount
$0
Row 61
Ins Carrier Name: FALLON COMMUNITY HEALTH PLAN
Filing Id
84037014197020
Form Id
100971004
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
FALLON COMMUNITY HEALTH PLAN
Ins Carrier EIN
23-7442369
Ins Carrier Naic Code
95541
Ins Contract Num
2255644
Ins Prsn Covered End of year Count
76
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
J
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$339,818
Wlfr Acquis Cost Amount
$0
Row 62
Ins Carrier Name: BLUE CROSS BLUE SHIELD OF GEORGIA, INC.
Filing Id
84037014197020
Form Id
100971001
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
BLUE CROSS BLUE SHIELD OF GEORGIA, INC.
Ins Carrier EIN
58-0469845
Ins Carrier Naic Code
54801
Ins Contract Num
1013259001
Ins Prsn Covered End of year Count
426
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
J
Wlfr Premium Rcvd Amount
$1,616,021
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$1,616,021
Wlfr Claims Paid Amount
$1,431,927
Wlfr Incr Reserve Amount
$25,775
Wlfr Incurred Claim Amount
$1,457,702
Wlfr Claims Chrgd Amount
$1,431,927
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$226,243
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$226,243
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$0
Wlfr Acquis Cost Amount
$0
Row 63
Ins Carrier Name: TRIPLE-S, INC.
Filing Id
84037014197020
Form Id
100971026
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
TRIPLE-S, INC.
Ins Carrier EIN
66-0555677
Ins Carrier Naic Code
55816
Ins Contract Num
1-11010-001
Ins Prsn Covered End of year Count
46
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AHK
Wlfr Premium Rcvd Amount
$158,282
Wlfr Unpaid Due Amount
$467
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$158,749
Wlfr Claims Paid Amount
$127,084
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$127,084
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$0
Wlfr Acquis Cost Amount
$0
Row 64
Ins Carrier Name: AETNA LIFE INSURANCE CO
Filing Id
84037014197020
Form Id
100970996
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
AETNA LIFE INSURANCE CO
Ins Carrier EIN
06-6033492
Ins Carrier Naic Code
60054
Ins Contract Num
800201
Ins Prsn Covered End of year Count
8,322
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AB
Wlfr Premium Rcvd Amount
$1,053,738
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$1,053,738
Wlfr Claims Paid Amount
$882,601
Wlfr Incr Reserve Amount
$17,609
Wlfr Incurred Claim Amount
$900,210
Wlfr Claims Chrgd Amount
$1,061,174
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$49,848
Wlfr Ret Taxes Amount
$13,596
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$-3,135
Wlfr Ret Total Amount
$60,309
Wlfr Refund Amount
$-67,745
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$2,426,754
Wlfr Acquis Cost Amount
$0
Row 65
Ins Carrier Name: KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Filing Id
84037014197020
Form Id
100971015
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
KAISER FOUNDATION HEALTH PLAN OF THE NORTHWEST
Ins Carrier EIN
93-0798039
Ins Carrier Naic Code
95540
Ins Contract Num
2939
Ins Prsn Covered End of year Count
746
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AJ
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$1,671,786
Wlfr Acquis Cost Amount
$0
Row 66
Ins Carrier Name: KAISER FOUNDATION HEALTH PLANS, INC.
Filing Id
84037014197020
Form Id
100971017
Schedule A EIN
22-1467904
Schedule A Plan Num
503
Schedule A Plan Year Begin Date
2008-01-01
Schedule A Tax Period
20081231
Ins Carrier Name
KAISER FOUNDATION HEALTH PLANS, INC.
Ins Carrier EIN
94-1340523
Ins Carrier Naic Code
00000
Ins Contract Num
104221
Ins Prsn Covered End of year Count
1,613
Ins Policy From Date
2008-01-01
Ins Policy To Date
2008-12-31
Ins Broker Comm Total Amount
$0
Ins Broker Fees Total Amount
$0
Pension End of year Gen Account Amount
$0
Pension End of year Sep Account Amount
$0
Pension Prem Paid Total Amount
$0
Pension Unpaid Premium Amount
$0
Pension Contract Cost Amount
$0
Pension End Prev Bal Amount
$0
Pension Contribution Dep Amount
$0
Pension Divnd Cr Dep Amount
$0
Pension Interest Cr Dur Yr Amount
$0
Pension Transfer From Amount
$0
Pension Other Amount
$0
Pension Total Additions Amount
$0
Pension Total Bal Addn Amount
$0
Pension Bnfts Dsbrsd Amount
$0
Pension Admin Chrg Amount
$0
Pension Transfer To Amount
$0
Pension Oth Ded Amount
$0
Pension Total Ded Amount
$0
Pension End of year Bal Amount
$0
Wlfr Type Bnft Indicator
AJ
Wlfr Premium Rcvd Amount
$0
Wlfr Unpaid Due Amount
$0
Wlfr Reserve Amount
$0
Wlfr Total Earned Prem Amount
$0
Wlfr Claims Paid Amount
$0
Wlfr Incr Reserve Amount
$0
Wlfr Incurred Claim Amount
$0
Wlfr Claims Chrgd Amount
$0
Wlfr Ret Commissions Amount
$0
Wlfr Ret Admin Amount
$0
Wlfr Ret Oth Cost Amount
$0
Wlfr Ret Oth Expense Amount
$0
Wlfr Ret Taxes Amount
$0
Wlfr Ret Charges Amount
$0
Wlfr Ret Oth Chrgs Amount
$0
Wlfr Ret Total Amount
$0
Wlfr Refund Amount
$0
Wlfr Held Bnfts Amount
$0
Wlfr Claims Reserve Amount
$0
Wlfr Oth Reserve Amount
$0
Wlfr Divnds Due Amount
$0
Wlfr Total Charges Paid Amount
$3,300,408
Wlfr Acquis Cost Amount
$0

Schedule C

Schedule C Provider

Provider 1

Provider details

Source fields
Row 1
Filing Id
84037014197020
Page Id
3
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020035
Row 2
Filing Id
84037014197020
Page Id
1
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
8010370014197020035
Provider 01 Position
CONTRACT ADMINISTRATOR
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$0
Provider 01 Srvc Code
12

Schedule C Provider

Provider 2

Provider details

Source fields
Row 3
Filing Id
84037014197020
Page Id
1
Page Seq
0
Page Row Num
2
Row Num
1
Image Form Id
8010370014197020035
Provider 01 Name
AETNA
Provider 01 EIN
06-6033492
Provider 01 Position
MEDICAL
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$8,404,660
Provider 01 Srvc Code
30

Schedule C Provider

Provider 3

Provider details

Source fields
Row 4
Filing Id
84037014197020
Page Id
2
Page Seq
2
Page Row Num
3
Row Num
10
Image Form Id
8010370014197020035
Provider 01 Name
SEGAL
Provider 01 EIN
13-1835864
Provider 01 Position
ACTUARIAL
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$10,000
Provider 01 Srvc Code
11

Schedule C Provider

Provider 4

Provider details

Source fields
Row 5
Filing Id
84037014197020
Page Id
2
Page Seq
3
Page Row Num
1
Row Num
11
Image Form Id
8010370014197020035
Provider 01 Name
J.H. COHN LLP
Provider 01 EIN
22-1478099
Provider 01 Position
ACCOUNTING
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$9,000
Provider 01 Srvc Code
10

Schedule C Provider

Provider 5

Provider details

Source fields
Row 6
Filing Id
84037014197020
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
2
Image Form Id
8010370014197020035
Provider 01 Name
UNITED HEALTHCARE
Provider 01 EIN
22-1211670
Provider 01 Position
MEDICAL
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$3,277,269
Provider 01 Srvc Code
30

Schedule C Provider

Provider 6

Provider details

Source fields
Row 7
Filing Id
84037014197020
Page Id
2
Page Seq
0
Page Row Num
2
Row Num
3
Image Form Id
8010370014197020035
Provider 01 Name
REED GROUP
Provider 01 EIN
84-0733950
Provider 01 Position
MEDICAL
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$621,095
Provider 01 Srvc Code
30

Schedule C Provider

Provider 7

Provider details

Source fields
Row 8
Filing Id
84037014197020
Page Id
2
Page Seq
0
Page Row Num
3
Row Num
4
Image Form Id
8010370014197020035
Provider 01 Name
MEDCO
Provider 01 EIN
22-3461740
Provider 01 Position
MEDICAL
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$276,888
Provider 01 Srvc Code
30

Schedule C Provider

Provider 8

Provider details

Source fields
Row 9
Filing Id
84037014197020
Page Id
2
Page Seq
1
Page Row Num
1
Row Num
5
Image Form Id
8010370014197020035
Provider 01 Name
MCDERMOTT, WILL & EMERY
Provider 01 EIN
36-1453176
Provider 01 Position
LEGAL
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$200,493
Provider 01 Srvc Code
22

Schedule C Provider

Provider 9

Provider details

Source fields
Row 10
Filing Id
84037014197020
Page Id
2
Page Seq
1
Page Row Num
2
Row Num
6
Image Form Id
8010370014197020035
Provider 01 Name
MERCER
Provider 01 EIN
13-2834414
Provider 01 Position
ACTUARIAL
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$161,192
Provider 01 Srvc Code
11

Schedule C Provider

Provider 10

Provider details

Source fields
Row 11
Filing Id
84037014197020
Page Id
2
Page Seq
1
Page Row Num
3
Row Num
7
Image Form Id
8010370014197020035
Provider 01 Name
MARSH
Provider 01 EIN
36-1436000
Provider 01 Position
RECORDKEEPING
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$103,950
Provider 01 Srvc Code
24

Schedule C Provider

Provider 11

Provider details

Source fields
Row 12
Filing Id
84037014197020
Page Id
2
Page Seq
2
Page Row Num
1
Row Num
8
Image Form Id
8010370014197020035
Provider 01 Name
PRICEWATERHOUSE COOPERS
Provider 01 EIN
13-4008324
Provider 01 Position
CONSULTING
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$23,969
Provider 01 Srvc Code
17

Schedule C Provider

Provider 12

Provider details

Source fields
Row 13
Filing Id
84037014197020
Page Id
2
Page Seq
2
Page Row Num
2
Row Num
9
Image Form Id
8010370014197020035
Provider 01 Name
DELOITTE & TOUCHE
Provider 01 EIN
13-5133500
Provider 01 Position
ACCOUNTING
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$20,000
Provider 01 Srvc Code
10

Schedule C Provider

Provider 13

Provider details

Source fields
Row 14
Filing Id
84037014197020
Schedule C EIN
22-1467904
Schedule C Plan number
503
Schedule C Plan Year Begin Date
2008-01-01
Schedule C Tax Period
20081231
Provider Total Comp Paid Amount
$12,026

Schedule H

Schedule H Financial Statement

Large plan result

Assets, contributions, fees, audit, and compliance fields reported for this large-plan filing.

End-of-year assets$44,011,502-$5,337,950 change

Balance Sheet

Beginning and end of plan year.

Total assets$49,349,452$44,011,502Decrease -$5,337,950 (-10.82%)
Total liabilities$0$0No change $0
Net assets$49,349,452$44,011,502Decrease -$5,337,950 (-10.82%)

Contributions

Employer contributions$150,746,016
Participant contributions$103,679,209
Other contributions$2,346,679
Total contributions$256,771,904

Income & Investment Result

Total income$257,359,051
Interest$587,147
Dividends$0
Net income$-5,337,950

Expenses & Fees

Benefits paid$249,576,459
Investment management$0
Administrative expenses$13,120,542
Total expenses$262,697,001

Accountant

FirmJ.H. COHN LLP
Firm EIN22-1478099

Compliance

Fidelity bondYes
Fidelity bond amount$405,000,000
Participant loans$0
Late contributionsNo
Schedule H source fields
Financial summary
Total assets at beginning of year: $49,349,452Total assets at end of year: $44,011,502Total liabilities at end of year: $0Net income or loss: $-5,337,950
Filing Id
84037014197020
Schedule H EIN
22-1467904
Schedule H Plan number
503
Schedule H Plan Year Begin Date
2008-01-01
Schedule H Tax Period
20081231
Non Interest Bear Cash Beginning of year Amount
$2
Employer Contribution Beginning of year Amount
$0
Participants Contribution Beginning of year Amount
$0
Other Receivables Beginning of year Amount
$587,039
Interest Bear Cash Beginning of year Amount
$48,762,411
Govt Sec Beginning of year Amount
$0
Corp Debt Preferred Beginning of year Amount
$0
Corp Debt Other Beginning of year Amount
$0
Pref Stock Beginning of year Amount
$0
Common Stock Beginning of year Amount
$0
Joint Venture Beginning of year Amount
$0
Real Estate Beginning of year Amount
$0
Other Loans Beginning of year Amount
$0
Participant loans at beginning of year
$0
Interest Common Tr Beginning of year Amount
$0
Interest Pool Sep Account Beginning of year Amount
$0
Interest Master Tr Beginning of year Amount
$0
Interest 103 12 Investment Beginning of year Amount
$0
Interest in registered investment companies at beginning of year
$0
Ins Co Gen Account Beginning of year Amount
$0
Oth Investment Beginning of year Amount
$0
Employer Sec Beginning of year Amount
$0
Employer Prop Beginning of year Amount
$0
Bldgs Used Beginning of year Amount
$0
Total assets at beginning of year
$49,349,452
Bnfts Payable Beginning of year Amount
$0
Oprtng Payable Beginning of year Amount
$0
Acquis Indbt Beginning of year Amount
$0
Other Liability Beginning of year Amount
$0
Total liabilities at beginning of year
$0
Net assets at beginning of year
$49,349,452
Non Interest Bear Cash End of year Amount
$2
Employer Contribution End of year Amount
$0
Participants Contribution End of year Amount
$0
Other Receivables End of year Amount
$985,219
Interest Bear Cash End of year Amount
$43,026,281
Govt Sec End of year Amount
$0
Corp Debt Preferred End of year Amount
$0
Corp Debt Other End of year Amount
$0
Pref Stock End of year Amount
$0
Common Stock End of year Amount
$0
Joint Venture End of year Amount
$0
Real Estate End of year Amount
$0
Other Loans End of year Amount
$0
Participant loans at end of year
$0
Interest Common Tr End of year Amount
$0
Interest Pool Sep Account End of year Amount
$0
Interest Master Tr End of year Amount
$0
Interest 103 12 Investment End of year Amount
$0
Interest in registered investment companies at end of year
$0
Ins Co Gen Account End of year Amount
$0
Oth Investment End of year Amount
$0
Employer Sec End of year Amount
$0
Employer Prop End of year Amount
$0
Bldgs Used End of year Amount
$0
Total assets at end of year
$44,011,502
Bnfts Payable End of year Amount
$0
Oprtng Payable End of year Amount
$0
Acquis Indbt End of year Amount
$0
Other Liability End of year Amount
$0
Total liabilities at end of year
$0
Net assets at end of year
$44,011,502
Employer contributions
$150,746,016
Participant contributions
$103,679,209
Oth Contribution Rcvd Amount
$2,346,679
Non Cash Contribution Bs Amount
$0
Total contributions
$256,771,904
Interest Bear Cash Amount
$587,147
Interest On Govt Sec Amount
$0
Interest On Corp Debt Amount
$0
Interest On Oth Loans Amount
$0
Interest on participant loans
$0
Interest On Oth Investment Amount
$0
Total interest income
$587,147
Divnd Pref Stock Amount
$0
Divnd Common Stock Amount
$0
Total dividend income
$0
Total Rents Amount
$0
Aggregate Proceeds Amount
$0
Aggregate Costs Amount
$0
Net gain or loss on sale of assets
$0
Unrealized Apprctn Re Amount
$0
Unrealized Apprctn Oth Amount
$0
Net unrealized appreciation or depreciation
$0
Gain Loss Com Trust Amount
$0
Gain Loss Pool Sep Amount
$0
Gain Loss Master Tr Amount
$0
Gain Loss 103 12 Investment Amount
$0
Gain or loss on registered investments
$0
Other Income Amount
$0
Total income
$257,359,051
Participant distributions
$209,444,365
Ins Carrier Bnfts Amount
$40,132,094
Oth Bnft Payment Amount
$0
Total benefit distributions
$249,576,459
Total Corrective Distribution Amount
$0
Total Dm Distribution Ptcp Lns A
0
Total Interest Expense Amount
$0
Professional Fees Amount
$516,660
Contract Admin Fees Amount
$0
Investment management fees
$0
Other Admin Fees Amount
$12,603,882
Total administrative expenses
$13,120,542
Total expenses
$262,697,001
Net income or loss
$-5,337,950
Total Transfers To Amount
$0
Transfers from other plans
$0
Accountant Opinion Type Indicator
Yes
Account Performed Limited Audit Indicator
No
Accountant firm name
J.H. COHN LLP
Accountant firm EIN
22-1478099
Failed to transmit participant contributions on time
No
Fail Transmit Contribution Amount
$0
Participant loans in default
No
Loans In Default Amount
$0
Leases in default
No
Leases In Default Amount
$0
Nonexempt transactions with parties in interest
No
Party In Interest Not Reported Amount
$0
Fidelity bond in place
Yes
Fidelity bond amount
$405,000,000
Loss discovered during year
No
Loss Discovered Dur Year Amount
$0
Assets with undetermined value
No
Asset Undeterm Valuation Amount
$0
Non-cash contributions reported
No
Non Cash Contribution Amount
$0
Assets held for investment
Yes
Reportable 5% transactions
Yes
All plan assets distributed
No
Resolution to terminate plan adopted
No
Res Terminate Plan Adpt Amount
$0