Fidelity bond in place
Yes
Filing
Automatic Data Processing Employee Welfare Benefit
AUTOMATIC DATA PROECESSING INC • EIN 22-1467904 • Plan year 2003
Filing Insights
Participants
Up30,234 → 30,759
525 • 1.74%
Assets
Down$66,224,043 → $56,423,536
-$9,800,507 • -14.80%
Investment Management Fee
0.00%$0
Admin expenses $10,591,126 • Total expenses $134,105,360
Filing Details
Context- Net investment result
- $-9,800,507
Status Flags
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
Yes
Benefits paid when due
Not reported
Plan blackout period
Not reported
Plan termination resolution adopted
No
Counterparties
| Provider | Services | Location | Direct Compensation | Related |
|---|---|---|---|---|
| DELOITTE & TOUCHE LLPEIN 13-3891517 | Accountant | - | - | - |
Company Timeline
This filing is highlighted inside the broader sponsor history.
| Year / Filing | Filings | Participants | Assets | Contributions | Contrib./Participant |
|---|---|---|---|---|---|
| 2024 | 3 | 34,516 | $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%. |
| 2023 | 3 | 34,557 | $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%. |
| 2022 | 3 | 33,407 | $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%. |
| 2021 | 3 | 31,257 | $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%. |
| 2020 | 3 | 30,924 | $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%. |
| 2019 | 3 | 32,235 | $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%. |
| 2018 | 3 | 32,065 | $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%. |
| 2017 | 3 | 33,347 | $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%. |
| 2016 | 3 | 31,952 | $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%. |
| 2015 | 3 | 30,106 | $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%. |
| 2014 | 3 | 35,998 | $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%. |
| 2013 | 3 | 36,107 | $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%. |
| 2012 | 3 | 35,812 | $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%. |
| 2011 | 3 | 34,226 | $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%. |
| 2010 | 3 | 32,605 | $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%. |
| 2009 | 4 | 31,495 | $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 | - | - | - |
| 2008 | 4 | 46,505 | $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 Benefit | - | 31,944 | $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 | - | - | - |
| 2007 | 4 | 46,000 | $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 | - | - | - |
| 2006 | 5 | 46,000 | $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 | - | - | - |
| 2005 | 5 | 46,000 | $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 | - | - | - |
| 2004 | 5 | 44,000 | $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 | - | - | - |
| 2003 | 5 | 31,739 | $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 | Current | 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 | - | - | - |
| 2002 | 5 | 31,271 | $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 | - | - | - |
| 2001 | 7 | 40,000 | $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 | - | - | - |
| 2000 | 6 | 41,000 | $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 | - | - | - |
| 1999 | 4 | 40,000 | $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
- 91037045170095
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- 56757990
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- 3040374357078020020
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- 91037045170095
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- 3040374357078020022
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- 91037045170095
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- 3040374357078020024
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- 91037045170095
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- 3040374357078020031
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- 3040374357078020033
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- 3040374357078020035
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- 91037045170095
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- 3040374357078020042
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- 91037045170095
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- 3040374357078020044
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- 91037045170095
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- 91037045170095
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- 91037045170095
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- 91037045170095
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- 56758026
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- 3040374357078020053
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- 91037045170095
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- 91037045170095
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- 91037045170095
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- 56758033
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- 3040374357078020015
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- 91037045170095
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- 91037045170095
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- 91037045170095
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- 3040374357078020009
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- 91037045170095
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- 56757983
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- 1
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- 3040374357078020010
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- Row 32
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- 91037045170095
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- 1
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- 3040374357078020012
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- Row 33
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- 91037045170095
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- 56757987
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- 1
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- 3040374357078020014
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- 91037045170095
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- 3040374357078020018
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- Row 35
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- 91037045170095
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- 56757992
- Page Id
- 1
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- 3040374357078020019
- Ins Broker Comm Pd 01 Amount
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- Row 36
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- 91037045170095
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- 56757994
- Page Id
- 1
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- 3040374357078020021
- Ins Broker Comm Pd 01 Amount
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- Row 37
- Filing Id
- 91037045170095
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- 56757996
- Page Id
- 1
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- 3040374357078020023
- Ins Broker Comm Pd 01 Amount
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- Row 38
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- 91037045170095
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- 56757998
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- 1
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- 3040374357078020025
- Ins Broker Comm Pd 01 Amount
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- Row 39
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- 91037045170095
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- 56758002
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- 1
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- 3040374357078020029
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- 91037045170095
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- 56758003
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- 3040374357078020030
- Ins Broker Comm Pd 01 Amount
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- Row 41
- Filing Id
- 91037045170095
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- 56758005
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- 1
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- 3040374357078020032
- Ins Broker Comm Pd 01 Amount
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- Row 42
- Filing Id
- 91037045170095
- Form Id
- 56758007
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- 1
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- 3040374357078020034
- Ins Broker Comm Pd 01 Amount
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- Row 43
- Filing Id
- 91037045170095
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- 56758009
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- 1
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- 1
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- 3040374357078020036
- Ins Broker Comm Pd 01 Amount
- $0
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- $0
- Row 44
- Filing Id
- 91037045170095
- Form Id
- 56758012
- Page Id
- 1
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- 0
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- 1
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- 3040374357078020039
- Ins Broker Comm Pd 01 Amount
- $0
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- $0
- Row 45
- Filing Id
- 91037045170095
- Form Id
- 56758014
- Page Id
- 1
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- 0
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- 1
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- 3040374357078020041
- Ins Broker Comm Pd 01 Amount
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- $0
- Row 46
- Filing Id
- 91037045170095
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- $0
- Row 47
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- 91037045170095
- Form Id
- 56758018
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- 1
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- 0
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- 1
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- 0
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- $0
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- $0
- Row 48
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- 91037045170095
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- 56758020
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- 1
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- 0
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- 1
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- 0
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- 3040374357078020047
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- $0
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- $0
- Row 49
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- 91037045170095
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- 56758023
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- 1
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- 0
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- 1
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- 0
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- 3040374357078020050
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- $0
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- $0
- Row 50
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- 91037045170095
- Form Id
- 56758025
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- 1
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- 0
- Page Row Num
- 1
- Row Num
- 0
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- 3040374357078020052
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- $0
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- $0
- Row 51
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- 91037045170095
- Form Id
- 56758027
- Page Id
- 1
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- 0
- Page Row Num
- 1
- Row Num
- 0
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- 3040374357078020054
- Ins Broker Comm Pd 01 Amount
- $0
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- $0
- Row 52
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- 91037045170095
- Form Id
- 56758029
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- 1
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- 0
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- 1
- Row Num
- 0
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- 3040374357078020056
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $0
- Row 53
- Filing Id
- 91037045170095
- Form Id
- 56758031
- Page Id
- 1
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3040374357078020058
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- $0
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- $0
- Row 54
- Filing Id
- 91037045170095
- Form Id
- 56757978
- Page Id
- 1
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- 0
- Page Row Num
- 1
- Row Num
- 0
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- 3040374357078020005
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- $0
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- $0
- Row 55
- Filing Id
- 91037045170095
- Form Id
- 56757989
- Page Id
- 1
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- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3040374357078020016
- Ins Broker Comm Pd 01 Amount
- $0
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- $0
- Row 56
- Filing Id
- 91037045170095
- Form Id
- 56758000
- Page Id
- 1
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- 0
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- 1
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- 0
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- 3040374357078020027
- Ins Broker Comm Pd 01 Amount
- $0
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- $0
- Row 57
- Filing Id
- 91037045170095
- Form Id
- 56758011
- Page Id
- 1
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- 0
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- 1
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- 0
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- 3040374357078020038
- Ins Broker Comm Pd 01 Amount
- $0
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- $0
- Row 58
- Filing Id
- 91037045170095
- Form Id
- 56758022
- Page Id
- 1
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- 0
- Page Row Num
- 1
- Row Num
- 0
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- 3040374357078020049
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $0
- Row 59
- Filing Id
- 91037045170095
- Form Id
- 56758032
- Page Id
- 1
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3040374357078020059
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $0
- Row 60
- Ins Carrier Name: TRIPLES-S INC
- Filing Id
- 91037045170095
- Form Id
- 56758030
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- TRIPLES-S INC
- Ins Carrier Naic Code
- 55816
- Ins Contract Num
- 111010001
- Ins Prsn Covered End of year Count
- 34
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $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
- $121,223
- Wlfr Acquis Cost Amount
- $0
- Row 61
- Ins Carrier Name: PRUDENTIAL FINANCIAL
- Filing Id
- 91037045170095
- Form Id
- 56757978
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- PRUDENTIAL FINANCIAL
- Ins Carrier EIN
- 22-1211670
- Ins Carrier Naic Code
- 68241
- Ins Contract Num
- 17900LTD
- Ins Prsn Covered End of year Count
- 18,404
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $4,519,629
- Wlfr Acquis Cost Amount
- $0
- Row 62
- Filing Id
- 91037045170095
- Form Id
- 56757981
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier EIN
- 23-2229683
- Ins Contract Num
- 005017
- Ins Prsn Covered End of year Count
- 785
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $2,031,796
- Wlfr Acquis Cost Amount
- $0
- Row 63
- Ins Carrier Name: HMO PACIFICARE
- Filing Id
- 91037045170095
- Form Id
- 56757982
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HMO PACIFICARE
- Ins Carrier EIN
- 94-3267522
- Ins Carrier Naic Code
- 95617
- Ins Contract Num
- CV201
- Ins Prsn Covered End of year Count
- 20
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $72,627
- Wlfr Acquis Cost Amount
- $0
- Row 64
- Ins Carrier Name: KAISER PERMANENTE
- Filing Id
- 91037045170095
- Form Id
- 56757983
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- KAISER PERMANENTE
- Ins Carrier EIN
- 94-1340523
- Ins Contract Num
- 209710000
- Ins Prsn Covered End of year Count
- 671
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- M
- Wlfr Type Bnft Oth Text
- HEALTH CARE SERVICE PLAN
- 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
- $1,484,446
- Wlfr Acquis Cost Amount
- $0
- Row 65
- Ins Carrier Name: KAISER PERMANENTE
- Filing Id
- 91037045170095
- Form Id
- 56757984
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- KAISER PERMANENTE
- Ins Carrier EIN
- 94-1340523
- Ins Contract Num
- 209717001
- Ins Prsn Covered End of year Count
- 21
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-03-20
- 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
- M
- Wlfr Type Bnft Oth Text
- HEALTH CARE SERVICE PLAN
- 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
- $44,407
- Wlfr Acquis Cost Amount
- $0
- Row 66
- Ins Carrier Name: KAISER PERMANENTE
- Filing Id
- 91037045170095
- Form Id
- 56757985
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- KAISER PERMANENTE
- Ins Carrier EIN
- 94-1340523
- Ins Contract Num
- 1042210000
- Ins Prsn Covered End of year Count
- 833
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- M
- Wlfr Type Bnft Oth Text
- HEALTH CARE SERVICE PLAN
- 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
- $1,759,616
- Wlfr Acquis Cost Amount
- $0
- Row 67
- Ins Carrier Name: KAISER PERMANENTE
- Filing Id
- 91037045170095
- Form Id
- 56757986
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- KAISER PERMANENTE
- Ins Carrier EIN
- 94-1340523
- Ins Contract Num
- 1042210027
- Ins Prsn Covered End of year Count
- 24
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- M
- Wlfr Type Bnft Oth Text
- HEALTH CARE SERVICE PLAN
- 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
- $60,383
- Wlfr Acquis Cost Amount
- $0
- Row 68
- Ins Carrier Name: PACIFICARE OF CALIFORNIA
- Filing Id
- 91037045170095
- Form Id
- 56757987
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- PACIFICARE OF CALIFORNIA
- Ins Carrier EIN
- 95-2931460
- Ins Carrier Naic Code
- 95893
- Ins Contract Num
- 146068
- Ins Prsn Covered End of year Count
- 437
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $1,845,347
- Wlfr Acquis Cost Amount
- $0
- Row 69
- Ins Carrier Name: PACIFICARE
- Filing Id
- 91037045170095
- Form Id
- 56757988
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- PACIFICARE
- Ins Carrier EIN
- 33-0115163
- Ins Carrier Naic Code
- 95174
- Ins Contract Num
- 084198
- Ins Prsn Covered End of year Count
- 32
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $181,574
- Wlfr Acquis Cost Amount
- $0
- Row 70
- Ins Carrier Name: PACIFICARE
- Filing Id
- 91037045170095
- Form Id
- 56757989
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- PACIFICARE
- Ins Carrier EIN
- 93-0938819
- Ins Carrier Naic Code
- 95893
- Ins Contract Num
- 036091
- Ins Prsn Covered End of year Count
- 31
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $157,904
- Wlfr Acquis Cost Amount
- $0
- Row 71
- Ins Carrier Name: PACIFCARE
- Filing Id
- 91037045170095
- Form Id
- 56757990
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- PACIFCARE
- Ins Carrier EIN
- 84-1011378
- Ins Carrier Naic Code
- 95434
- Ins Contract Num
- D5901
- Ins Prsn Covered End of year Count
- 13
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $82,378
- Wlfr Acquis Cost Amount
- $0
- Row 72
- Ins Carrier Name: KAISER PERMAMENTE
- Filing Id
- 91037045170095
- Form Id
- 56757991
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- KAISER PERMAMENTE
- Ins Carrier EIN
- 93-0798039
- Ins Carrier Naic Code
- 95540
- Ins Prsn Covered End of year Count
- 837
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- M
- Wlfr Type Bnft Oth Text
- HEALTH CARE SERVICE PLAN
- 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
- $1,414,296
- Wlfr Acquis Cost Amount
- $0
- Row 73
- Ins Carrier Name: KAISER PERMANENTE
- Filing Id
- 91037045170095
- Form Id
- 56757992
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- KAISER PERMANENTE
- Ins Carrier EIN
- 52-0954463
- Ins Carrier Naic Code
- 95639
- Ins Contract Num
- 759310
- Ins Prsn Covered End of year Count
- 378
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 1900-01-01
- 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
- M
- Wlfr Type Bnft Oth Text
- HEALTH CARE SERVICE
- 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
- $451,996
- Wlfr Acquis Cost Amount
- $0
- Row 74
- Ins Carrier Name: KAISER PERMANENTE
- Filing Id
- 91037045170095
- Form Id
- 56757993
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- KAISER PERMANENTE
- Ins Carrier EIN
- 84-0591617
- Ins Carrier Naic Code
- 95669
- Ins Contract Num
- 024497
- Ins Prsn Covered End of year Count
- 108
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- M
- Wlfr Type Bnft Oth Text
- HOSPITAL, SURGICAL, MEDICAL
- 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
- $288,934
- Wlfr Acquis Cost Amount
- $0
- Row 75
- Ins Carrier Name: HUMANA HEALTH PLAN INC
- Filing Id
- 91037045170095
- Form Id
- 56757994
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HUMANA HEALTH PLAN INC
- Ins Carrier EIN
- 61-1013183
- Ins Carrier Naic Code
- 95885
- Ins Contract Num
- D9204
- Ins Prsn Covered End of year Count
- 45
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $0
- Wlfr Acquis Cost Amount
- $0
- Row 76
- Ins Carrier Name: HUMANA MEDICAL PLAN INC
- Filing Id
- 91037045170095
- Form Id
- 56757995
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HUMANA MEDICAL PLAN INC
- Ins Carrier EIN
- 61-1103898
- Ins Carrier Naic Code
- 95270
- Ins Contract Num
- N1415
- Ins Prsn Covered End of year Count
- 20
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $95,242
- Wlfr Acquis Cost Amount
- $0
- Row 77
- Ins Carrier Name: HUMANA MEDICAL PLAN INC
- Filing Id
- 91037045170095
- Form Id
- 56757996
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HUMANA MEDICAL PLAN INC
- Ins Carrier EIN
- 61-1103898
- Ins Carrier Naic Code
- 95270
- Ins Contract Num
- N1414
- Ins Prsn Covered End of year Count
- 20
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $99,995
- Wlfr Acquis Cost Amount
- $0
- Row 78
- Ins Carrier Name: BLUECROSS BLUESHIELD
- Filing Id
- 91037045170095
- Form Id
- 56758001
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- BLUECROSS BLUESHIELD
- Ins Carrier EIN
- 99-0040115
- Ins Carrier Naic Code
- 49948
- Ins Contract Num
- 94020
- Ins Prsn Covered End of year Count
- 25
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $52,473
- Wlfr Acquis Cost Amount
- $0
- Row 79
- Ins Carrier Name: BLUECROSS BLUE SHIELD
- Filing Id
- 91037045170095
- Form Id
- 56758002
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- BLUECROSS BLUE SHIELD
- Ins Carrier EIN
- 36-1236610
- Ins Carrier Naic Code
- 70670
- Ins Contract Num
- H06201
- Ins Prsn Covered End of year Count
- 150
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $421,590
- Wlfr Acquis Cost Amount
- $0
- Row 80
- Ins Carrier Name: OPTIMUM CHOICE INC
- Filing Id
- 91037045170095
- Form Id
- 56758003
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- 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
- 45
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $227,761
- Wlfr Acquis Cost Amount
- $0
- Row 81
- Ins Carrier Name: FALLON COMMUNITY HEALTH PLAN
- Filing Id
- 91037045170095
- Form Id
- 56758004
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- FALLON COMMUNITY HEALTH PLAN
- Ins Carrier EIN
- 23-7442369
- Ins Carrier Naic Code
- 95541
- Ins Contract Num
- 4448118
- Ins Prsn Covered End of year Count
- 223
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $1,415,672
- Wlfr Acquis Cost Amount
- $0
- Row 82
- Ins Carrier Name: FALLON COMMUNITY HEALTH PLAN
- Filing Id
- 91037045170095
- Form Id
- 56758005
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- FALLON COMMUNITY HEALTH PLAN
- Ins Carrier EIN
- 23-7442369
- Ins Carrier Naic Code
- 95541
- Ins Contract Num
- 4448120
- Ins Prsn Covered End of year Count
- 67
- Ins Policy From Date
- 2001-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $418,383
- Wlfr Acquis Cost Amount
- $0
- Row 83
- Ins Carrier Name: FALLON COMMUNITY HEALTH PLAN
- Filing Id
- 91037045170095
- Form Id
- 56758006
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- FALLON COMMUNITY HEALTH PLAN
- Ins Carrier EIN
- 23-7442369
- Ins Carrier Naic Code
- 95541
- Ins Contract Num
- 4448125
- Ins Prsn Covered End of year Count
- 129
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $769,591
- Wlfr Acquis Cost Amount
- $0
- Row 84
- Ins Carrier Name: FALLON COMMUNITY HEALTH PLAN
- Filing Id
- 91037045170095
- Form Id
- 56758007
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- FALLON COMMUNITY HEALTH PLAN
- Ins Carrier EIN
- 23-7442369
- Ins Carrier Naic Code
- 95541
- Ins Contract Num
- 4448126
- Ins Prsn Covered End of year Count
- 58
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $370,871
- Wlfr Acquis Cost Amount
- $0
- Row 85
- Ins Carrier Name: HUMANA MEDICAL PLAN INC
- Filing Id
- 91037045170095
- Form Id
- 56757997
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HUMANA MEDICAL PLAN INC
- Ins Carrier EIN
- 61-1103898
- Ins Carrier Naic Code
- 95270
- Ins Contract Num
- N1411
- Ins Prsn Covered End of year Count
- 1
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $10,111
- Wlfr Acquis Cost Amount
- $0
- Row 86
- Ins Carrier Name: HUMANA MEDICAL PLAN INC
- Filing Id
- 91037045170095
- Form Id
- 56757998
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HUMANA MEDICAL PLAN INC
- Ins Carrier EIN
- 61-1103898
- Ins Carrier Naic Code
- 95270
- Ins Contract Num
- N1401
- Ins Prsn Covered End of year Count
- 8
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $36,019
- Wlfr Acquis Cost Amount
- $0
- Row 87
- Ins Carrier Name: HUMANA HEALTH PLAN INC
- Filing Id
- 91037045170095
- Form Id
- 56757999
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HUMANA HEALTH PLAN INC
- Ins Carrier EIN
- 61-1013183
- Ins Prsn Covered End of year Count
- 0
- 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
- $148,577
- Wlfr Acquis Cost Amount
- $0
- Row 88
- Ins Carrier Name: BLUECROSS BLUESHIELD
- Filing Id
- 91037045170095
- Form Id
- 56758000
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- BLUECROSS BLUESHIELD
- Ins Carrier EIN
- 62-0342590
- Ins Carrier Naic Code
- 54801
- Ins Contract Num
- 1013259001
- Ins Prsn Covered End of year Count
- 373
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $905,905
- Wlfr Acquis Cost Amount
- $0
- Row 89
- Ins Carrier Name: FALLON COMMUNITY HEALTH PLAN
- Filing Id
- 91037045170095
- Form Id
- 56758008
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- FALLON COMMUNITY HEALTH PLAN
- Ins Carrier EIN
- 23-7442369
- Ins Carrier Naic Code
- 95541
- Ins Contract Num
- 2237941
- Ins Prsn Covered End of year Count
- 202
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $422,082
- Wlfr Acquis Cost Amount
- $0
- Row 90
- Ins Carrier Name: TUFTS ASSOCIATED HEALTH MAINTENANCE ORG INC
- Filing Id
- 91037045170095
- Form Id
- 56758009
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- TUFTS ASSOCIATED HEALTH MAINTENANCE ORG INC
- Ins Carrier EIN
- 04-2674079
- Ins Carrier Naic Code
- 95688
- Ins Contract Num
- 04437000
- Ins Prsn Covered End of year Count
- 201
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $213,782
- Wlfr Acquis Cost Amount
- $0
- Row 91
- Ins Carrier Name: TUFTS ASSOCIATED HELATH MAINTENANCE ORG INC
- Filing Id
- 91037045170095
- Form Id
- 56758010
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- TUFTS ASSOCIATED HELATH MAINTENANCE ORG INC
- Ins Carrier EIN
- 04-2674079
- Ins Carrier Naic Code
- 95688
- Ins Contract Num
- 04437000
- Ins Prsn Covered End of year Count
- 0
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $851,867
- Wlfr Acquis Cost Amount
- $0
- Row 92
- Ins Carrier Name: BLUE CROSS BLUE SHIELD
- Filing Id
- 91037045170095
- Form Id
- 56758011
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- BLUE CROSS BLUE SHIELD
- Ins Carrier EIN
- 04-1045815
- Ins Carrier Naic Code
- 53228
- Ins Contract Num
- 0331405
- Ins Prsn Covered End of year Count
- 477
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- Ins Broker Comm Total Amount
- $21,038
- 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
- $1,404,915
- Wlfr Acquis Cost Amount
- $0
- Row 93
- Ins Carrier Name: CIGNA HEALTHCARE OF MA
- Filing Id
- 91037045170095
- Form Id
- 56758012
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- CIGNA HEALTHCARE OF MA
- Ins Carrier EIN
- 06-1141175
- Ins Carrier Naic Code
- 95520
- Ins Contract Num
- 3205640
- Ins Prsn Covered End of year Count
- 0
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $225,429
- Wlfr Acquis Cost Amount
- $0
- Row 94
- Ins Carrier Name: BLUE CARE NETWORK
- Filing Id
- 91037045170095
- Form Id
- 56758013
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- BLUE CARE NETWORK
- Ins Carrier EIN
- 38-2359234
- Ins Carrier Naic Code
- 95861
- Ins Contract Num
- 89231000
- Ins Prsn Covered End of year Count
- 63
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- M
- Wlfr Type Bnft Oth Text
- WELFARE PLAN
- 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
- $175,730
- Wlfr Acquis Cost Amount
- $0
- Row 95
- Ins Carrier Name: HEALTH ALLIANCE PLAN
- Filing Id
- 91037045170095
- Form Id
- 56758014
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HEALTH ALLIANCE PLAN
- Ins Carrier EIN
- 38-2242827
- Ins Carrier Naic Code
- 95844
- Ins Contract Num
- 94111AA
- Ins Prsn Covered End of year Count
- 92
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $228,681
- Wlfr Acquis Cost Amount
- $0
- Row 96
- Ins Carrier Name: M-CARE INC
- Filing Id
- 91037045170095
- Form Id
- 56758015
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- M-CARE INC
- Ins Carrier EIN
- 38-2649504
- Ins Carrier Naic Code
- 95449
- Ins Contract Num
- 0050000000
- Ins Prsn Covered End of year Count
- 110
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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 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
- $542,047
- Wlfr Acquis Cost Amount
- $0
- Row 97
- Ins Carrier Name: CARE CHOICES
- Filing Id
- 91037045170095
- Form Id
- 56758016
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- CARE CHOICES
- Ins Carrier EIN
- 38-2694901
- Ins Carrier Naic Code
- 95452
- Ins Contract Num
- 1005920001
- Ins Prsn Covered End of year Count
- 41
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- Ins Broker Comm Total Amount
- $4,770
- 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
- $104,281
- Wlfr Acquis Cost Amount
- $0
- Row 98
- Ins Carrier Name: CARE CHOICES
- Filing Id
- 91037045170095
- Form Id
- 56758017
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- CARE CHOICES
- Ins Carrier EIN
- 38-2694901
- Ins Carrier Naic Code
- 95452
- Ins Contract Num
- 1005929504
- Ins Prsn Covered End of year Count
- 5
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- Ins Broker Comm Total Amount
- $1,182
- 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
- $24,817
- Wlfr Acquis Cost Amount
- $0
- Row 99
- Ins Carrier Name: HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY
- Filing Id
- 91037045170095
- Form Id
- 56758018
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HORIZON BLUE CROSS BLUE SHIELD OF NEW JERSEY
- Ins Carrier EIN
- 22-0999690
- Ins Carrier Naic Code
- 55069
- Ins Contract Num
- 85006
- Ins Prsn Covered End of year Count
- 78
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $84,226
- Wlfr Acquis Cost Amount
- $0
- Row 100
- Ins Carrier Name: HORIZON HEALTHCARE OF NEW JERSEY INC
- Filing Id
- 91037045170095
- Form Id
- 56758019
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- 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
- 78
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $0
- Wlfr Acquis Cost Amount
- $0
- Row 101
- Ins Carrier Name: OXFORD HEALTH PLANS
- Filing Id
- 91037045170095
- Form Id
- 56758020
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- OXFORD HEALTH PLANS
- Ins Carrier EIN
- 06-1118515
- Ins Carrier Naic Code
- 01182
- Ins Contract Num
- AD08001
- Ins Prsn Covered End of year Count
- 56
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $201,509
- Wlfr Acquis Cost Amount
- $0
- Row 102
- Ins Carrier Name: EXCELLUS
- Filing Id
- 91037045170095
- Form Id
- 56758021
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- EXCELLUS
- Ins Carrier Naic Code
- 55107
- Ins Contract Num
- 160612270
- Ins Prsn Covered End of year Count
- 2
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- ABC
- 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
- $74,974
- Wlfr Acquis Cost Amount
- $0
- Row 103
- Filing Id
- 91037045170095
- Form Id
- 56758022
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier EIN
- 16-1105741
- Ins Carrier Naic Code
- 55204
- Ins Contract Num
- 00301659
- Ins Prsn Covered End of year Count
- 45
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $73,162
- Wlfr Acquis Cost Amount
- $0
- Row 104
- Ins Carrier Name: EXCELLUS CENTRAL NEW YORK REGION
- Filing Id
- 91037045170095
- Form Id
- 56758023
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- EXCELLUS CENTRAL NEW YORK REGION
- Ins Carrier EIN
- 15-0329043
- Ins Carrier Naic Code
- 55107
- Ins Contract Num
- 500044002
- Ins Prsn Covered End of year Count
- 3
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $14,953
- Wlfr Acquis Cost Amount
- $0
- Row 105
- Ins Carrier Name: HIP HEALTH PLANS
- Filing Id
- 91037045170095
- Form Id
- 56758024
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- 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
- 92
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $244,140
- Wlfr Acquis Cost Amount
- $0
- Row 106
- Ins Carrier Name: MVP HEALTH PLAN INC
- Filing Id
- 91037045170095
- Form Id
- 56758025
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- MVP HEALTH PLAN INC
- Ins Carrier EIN
- 14-1640868
- Ins Contract Num
- 2121640001
- Ins Prsn Covered End of year Count
- 30
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $183,047
- Wlfr Acquis Cost Amount
- $0
- Row 107
- Ins Carrier Name: HEALTH NET OF THE NORTHEAST
- Filing Id
- 91037045170095
- Form Id
- 56758026
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HEALTH NET OF THE NORTHEAST
- Ins Carrier EIN
- 22-3241303
- Ins Carrier Naic Code
- 95351
- Ins Contract Num
- 35032C
- Ins Prsn Covered End of year Count
- 31
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $55,014
- Wlfr Acquis Cost Amount
- $0
- Row 108
- Ins Carrier Name: HEALTH NET OF THE NORTHEAST
- Filing Id
- 91037045170095
- Form Id
- 56758027
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HEALTH NET OF THE NORTHEAST
- Ins Carrier EIN
- 22-3241303
- Ins Carrier Naic Code
- 95351
- Ins Contract Num
- 035032
- Ins Prsn Covered End of year Count
- 361
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $918,418
- Wlfr Acquis Cost Amount
- $0
- Row 109
- Ins Carrier Name: INDEPENDENT HEALTH
- Filing Id
- 91037045170095
- Form Id
- 56758028
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- INDEPENDENT HEALTH
- Ins Carrier EIN
- 16-1080163
- Ins Carrier Naic Code
- 95308
- Ins Contract Num
- 30944H
- Ins Prsn Covered End of year Count
- 114
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $250,291
- Wlfr Acquis Cost Amount
- $0
- Row 110
- Ins Carrier Name: HIGHMARK BLUE SHIELD
- Filing Id
- 91037045170095
- Form Id
- 56758029
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- HIGHMARK BLUE SHIELD
- Ins Carrier EIN
- 25-1522457
- Ins Contract Num
- 5811130
- Ins Prsn Covered End of year Count
- 34
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $144,246
- Wlfr Acquis Cost Amount
- $0
- Row 111
- Ins Carrier Name: KAISER PERMANENTE
- Filing Id
- 91037045170095
- Form Id
- 56758031
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- KAISER PERMANENTE
- Ins Carrier EIN
- 52-0954463
- Ins Carrier Naic Code
- 95639
- Ins Contract Num
- 75931
- Ins Prsn Covered End of year Count
- 51
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $319,215
- Wlfr Acquis Cost Amount
- $0
- Row 112
- Ins Carrier Name: KAISER PERMANENTE
- Filing Id
- 91037045170095
- Form Id
- 56758032
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- KAISER PERMANENTE
- Ins Carrier EIN
- 34-0922268
- Ins Carrier Naic Code
- 95204
- Ins Contract Num
- 4764
- Ins Prsn Covered End of year Count
- 12
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $27,766
- Wlfr Acquis Cost Amount
- $0
- Row 113
- Ins Carrier Name: THE WELLNESS PLAN
- Filing Id
- 91037045170095
- Form Id
- 56758033
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- THE WELLNESS PLAN
- Ins Carrier EIN
- 38-2008890
- Ins Carrier Naic Code
- 95471
- Ins Contract Num
- 0006040604
- Ins Prsn Covered End of year Count
- 39
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $94,111
- Wlfr Acquis Cost Amount
- $0
- Row 114
- Ins Carrier Name: THE HARTFORD LIFE & ACCIDENT COMPANY
- Filing Id
- 91037045170095
- Form Id
- 56757979
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- THE HARTFORD LIFE & ACCIDENT COMPANY
- Ins Carrier EIN
- 06-0838648
- Ins Carrier Naic Code
- 70815
- Ins Contract Num
- GRH 710133
- Ins Prsn Covered End of year Count
- 21,276
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- Ins Broker Comm Total Amount
- $35,107
- 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
- I
- 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
- $585,124
- Wlfr Acquis Cost Amount
- $0
- Row 115
- Ins Carrier Name: AETNA INC
- Filing Id
- 91037045170095
- Form Id
- 56757980
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- AETNA INC
- Ins Carrier EIN
- 06-6033492
- Ins Carrier Naic Code
- 60054
- Ins Contract Num
- 800201ERG
- Ins Prsn Covered End of year Count
- 12,457
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $619,507
- Wlfr Unpaid Due Amount
- $0
- Wlfr Reserve Amount
- $0
- Wlfr Total Earned Prem Amount
- $619,507
- Wlfr Claims Paid Amount
- $373,790
- Wlfr Incr Reserve Amount
- $22,308
- Wlfr Incurred Claim Amount
- $396,098
- 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
- $11,920
- Wlfr Ret Taxes Amount
- $14,701
- Wlfr Ret Charges Amount
- $0
- Wlfr Ret Oth Chrgs Amount
- $-2,337
- Wlfr Ret Total Amount
- $24,284
- Wlfr Refund Indicator
- No
- Wlfr Refund Amount
- $199,125
- 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
- $2,194,545
- Wlfr Acquis Cost Amount
- $0
- Row 116
- Ins Carrier Name: AIG LIFE INSURANCE COMPANY
- Filing Id
- 91037045170095
- Form Id
- 56757975
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- AIG LIFE INSURANCE COMPANY
- Ins Carrier EIN
- 25-1118523
- Ins Prsn Covered End of year Count
- 0
- 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
- M
- Wlfr Type Bnft Oth Text
- EXTENDED ACCIDENTAL DEATH & DISMEMB
- 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
- $345,320
- Wlfr Acquis Cost Amount
- $0
- Row 117
- Ins Carrier Name: AIG LIFE INSURANCE COMPANY
- Filing Id
- 91037045170095
- Form Id
- 56757976
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- AIG LIFE INSURANCE COMPANY
- Ins Carrier EIN
- 25-1118523
- Ins Prsn Covered End of year Count
- 0
- 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
- M
- Wlfr Type Bnft Oth Text
- EXTENDED ACCIDENTAL DEATH & DISMEMB
- 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
- $890,259
- Wlfr Acquis Cost Amount
- $0
- Row 118
- Ins Carrier Name: PRUDENTIAL FINANCIAL
- Filing Id
- 91037045170095
- Form Id
- 56757977
- Schedule A EIN
- 22-1467904
- Schedule A Plan Num
- 503
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- PRUDENTIAL FINANCIAL
- Ins Carrier EIN
- 22-1211670
- Ins Carrier Naic Code
- 68241
- Ins Contract Num
- 179001
- Ins Prsn Covered End of year Count
- 28,548
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- 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
- $2,752,076
- Wlfr Acquis Cost Amount
- $0
Schedule C
Schedule C Provider
Provider 1
Provider details
Source fields
- Row 1
- Filing Id
- 91037045170095
- Page Id
- 1
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3040374357078020061
- Row 2
- Filing Id
- 91037045170095
- Page Id
- 1
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3040374357078020061
- 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
- 91037045170095
- Page Id
- 1
- Page Seq
- 0
- Page Row Num
- 2
- Row Num
- 1
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- PAID PRESCRIPTION LLC
- Provider 01 EIN
- 95-3204551
- Provider 01 Salary Amount
- $200,474
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 12
Schedule C Provider
Provider 3
Provider details
Source fields
- Row 4
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 2
- Page Row Num
- 3
- Row Num
- 10
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- WILLIAM A MERCER
- Provider 01 EIN
- 13-2834414
- Provider 01 Salary Amount
- $201,336
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 19
Schedule C Provider
Provider 4
Provider details
Source fields
- Row 5
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 3
- Page Row Num
- 1
- Row Num
- 11
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- ADP BENEFIT SERVICES
- Provider 01 EIN
- 22-3339704
- Provider 01 Salary Amount
- $257,969
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 99
Schedule C Provider
Provider 5
Provider details
Source fields
- Row 6
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 3
- Page Row Num
- 2
- Row Num
- 12
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- MCDERMOTT WILL & EMERGENCY
- Provider 01 EIN
- 36-1453176
- Provider 01 Salary Amount
- $49,498
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 99
Schedule C Provider
Provider 6
Provider details
Source fields
- Row 7
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 3
- Page Row Num
- 3
- Row Num
- 13
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- MARSH USA INC
- Provider 01 EIN
- 36-1436000
- Provider 01 Salary Amount
- $103,528
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 24
Schedule C Provider
Provider 7
Provider details
Source fields
- Row 8
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 2
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- PRUDENTIAL INSURANCE COMPANY
- Provider 01 EIN
- 22-1211670
- Provider 01 Salary Amount
- $1,922,815
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 12
Schedule C Provider
Provider 8
Provider details
Source fields
- Row 9
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 2
- Row Num
- 3
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- AETNA US HEALTHCARE
- Provider 01 EIN
- 06-6033492
- Provider 01 Salary Amount
- $6,846,492
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 12
Schedule C Provider
Provider 9
Provider details
Source fields
- Row 10
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 3
- Row Num
- 4
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- MEDCO HEALTH SOLUTIONS INC
- Provider 01 EIN
- 22-3461740
- Provider 01 Salary Amount
- $154,630
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 12
Schedule C Provider
Provider 10
Provider details
Source fields
- Row 11
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 1
- Page Row Num
- 1
- Row Num
- 5
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- REED GROUP LTD
- Provider 01 EIN
- 84-0733950
- Provider 01 Salary Amount
- $362,244
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 12
Schedule C Provider
Provider 11
Provider details
Source fields
- Row 12
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 1
- Page Row Num
- 2
- Row Num
- 6
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- THE HARTFORD
- Provider 01 EIN
- 06-0838648
- Provider 01 Salary Amount
- $456,432
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 12
Schedule C Provider
Provider 12
Provider details
Source fields
- Row 13
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 1
- Page Row Num
- 3
- Row Num
- 7
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- SEGAL COMPANY
- Provider 01 EIN
- 13-1835864
- Provider 01 Salary Amount
- $10,000
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 12
Schedule C Provider
Provider 13
Provider details
Source fields
- Row 14
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 2
- Page Row Num
- 1
- Row Num
- 8
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- AT&T
- Provider 01 EIN
- 22-2473192
- Provider 01 Salary Amount
- $7,178
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 99
Schedule C Provider
Provider 14
Provider details
Source fields
- Row 15
- Filing Id
- 91037045170095
- Page Id
- 2
- Page Seq
- 2
- Page Row Num
- 2
- Row Num
- 9
- Image Form Id
- 3040374357078020061
- Provider 01 Name
- NATIONAL COMMITTEE FOR QA
- Provider 01 EIN
- 52-1191985
- Provider 01 Salary Amount
- $26,667
- Provider 01 Fees Amount
- $0
- Provider 01 Srvc Code
- 99
Schedule C Provider
Provider 15
Provider details
Source fields
- Row 16
- Filing Id
- 91037045170095
- Schedule C EIN
- 22-1467904
- Schedule C Plan number
- 503
- Schedule C Plan Year Begin Date
- 2003-01-01
- Schedule C Tax Period
- 20031231
- Provider Total Comp Paid Amount
- $0
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$56,423,536-$9,800,507 change
Balance Sheet
Beginning and end of plan year.
Total assets$66,224,043$56,423,536Decrease -$9,800,507 (-14.80%)
Total liabilities$0$0No change $0
Net assets$66,224,043$56,423,536Decrease -$9,800,507 (-14.80%)
Contributions
Employer contributions$69,614,558
Participant contributions$54,152,043
Other contributions$0
Total contributions$123,766,601
Income & Investment Result
Total income$124,304,853
Interest$531,789
Dividends$0
Net income$-9,800,507
Expenses & Fees
Benefits paid$123,514,234
Investment management$0
Administrative expenses$10,591,126
Total expenses$134,105,360
Accountant
FirmDELOITTE & TOUCHE LLP
Firm EIN13-3891517
Compliance
Fidelity bondYes
Fidelity bond amount$75,000,000
Participant loans$0
Late contributionsNo
Schedule H source fields
- Financial summary
- Total assets at beginning of year: $66,224,043Total assets at end of year: $56,423,536Total liabilities at end of year: $0Net income or loss: $-9,800,507
- Filing Id
- 91037045170095
- Schedule H EIN
- 22-1467904
- Schedule H Plan number
- 503
- Schedule H Plan Year Begin Date
- 2003-01-01
- Schedule H Tax Period
- 20031231
- Non Interest Bear Cash Beginning of year Amount
- $4,465
- Employer Contribution Beginning of year Amount
- $0
- Participants Contribution Beginning of year Amount
- $0
- Other Receivables Beginning of year Amount
- $0
- Interest Bear Cash Beginning of year Amount
- $5,178,356
- Govt Sec Beginning of year Amount
- $0
- Corp Debt Preferred Beginning of year Amount
- $0
- Corp Debt Other Beginning of year Amount
- $61,041,222
- 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
- $66,224,043
- 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
- $66,224,043
- Non Interest Bear Cash End of year Amount
- $113,897
- Employer Contribution End of year Amount
- $0
- Participants Contribution End of year Amount
- $0
- Other Receivables End of year Amount
- $0
- Interest Bear Cash End of year Amount
- $5,775,150
- Govt Sec End of year Amount
- $0
- Corp Debt Preferred End of year Amount
- $0
- Corp Debt Other End of year Amount
- $50,534,489
- 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
- $56,423,536
- 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
- $56,423,536
- Employer contributions
- $69,614,558
- Participant contributions
- $54,152,043
- Oth Contribution Rcvd Amount
- $0
- Non Cash Contribution Bs Amount
- $0
- Total contributions
- $123,766,601
- Interest Bear Cash Amount
- $52,331
- Interest On Govt Sec Amount
- $0
- Interest On Corp Debt Amount
- $479,458
- Interest On Oth Loans Amount
- $0
- Interest on participant loans
- $0
- Interest On Oth Investment Amount
- $0
- Total interest income
- $531,789
- 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
- $6,463
- Unrealized Apprctn Oth Amount
- $0
- Net unrealized appreciation or depreciation
- $6,463
- 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
- $124,304,853
- Participant distributions
- $113,253,100
- Ins Carrier Bnfts Amount
- $10,261,134
- Oth Bnft Payment Amount
- $0
- Total benefit distributions
- $123,514,234
- Total Corrective Distribution Amount
- $0
- Total Dm Distribution Ptcp Lns A
- 0
- Total Interest Expense Amount
- $0
- Professional Fees Amount
- $304,864
- Contract Admin Fees Amount
- $9,944,950
- Investment management fees
- $0
- Other Admin Fees Amount
- $341,312
- Total administrative expenses
- $10,591,126
- Total expenses
- $134,105,360
- Net income or loss
- $-9,800,507
- Total Transfers To Amount
- $0
- Transfers from other plans
- $0
- Accountant Opinion Type Indicator
- Yes
- Account Performed Limited Audit Indicator
- Yes
- Accountant firm name
- DELOITTE & TOUCHE LLP
- Accountant firm EIN
- 13-3891517
- 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
- $75,000,000
- 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
- Yes
- Resolution to terminate plan adopted
- No
- Res Terminate Plan Adpt Amount
- $0