Schedule A
- Row 1
- Filing Id
- 84037347325318
- Form Id
- 93408334
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7020378347325060002
- Ins Broker 01 Name
- COMMERCE INSURANCE SERVICES, INC.
- Ins Broker 01 Street Addr
- 1701 ROUTE 70 EAST, P.O. BOX 2060
- Ins Broker 01 City
- CHERRY HILL
- Ins Broker 01 State
- NJ
- Ins Broker 01 ZIP Code
- 08034
- Ins Broker Comm Pd 01 Amount
- $5,047
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 2
- Filing Id
- 84037347325318
- Form Id
- 93408337
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7020378347325060005
- Ins Broker 01 Name
- COMMERCE BANC INSURANCE SERVICES
- Ins Broker 01 Street Addr
- 1701 ROUTE 70 EAST,P.O. BOX 2060
- Ins Broker 01 City
- CHERRY HILL
- Ins Broker 01 State
- NJ
- Ins Broker 01 ZIP Code
- 08034
- Ins Broker Comm Pd 01 Amount
- $33,068
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 3
- Filing Id
- 84037347325318
- Form Id
- 93408336
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7020378347325060004
- Ins Broker 01 Name
- COMMERCE INSURANCE SERVICES, INC.
- Ins Broker 01 Street Addr
- 1700 ROUTE 70 EAST, P.O. BOX 2060
- Ins Broker 01 City
- CHERRY HILL
- Ins Broker 01 State
- NJ
- Ins Broker 01 ZIP Code
- 08034
- Ins Broker Comm Pd 01 Amount
- $5,588
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 4
- Filing Id
- 84037347325318
- Form Id
- 93408338
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7020378347325060006
- Ins Broker 01 Name
- AMERIHEALTH ADMINISTRATORS
- Ins Broker 01 Street Addr
- 720 BLAIR MILL ROAD
- Ins Broker 01 City
- HORSHAM
- Ins Broker 01 State
- PA
- Ins Broker 01 ZIP Code
- 19044
- Ins Broker Comm Pd 01 Amount
- $59,088
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 5
- Filing Id
- 84037347325318
- Form Id
- 93408335
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7020378347325060003
- Ins Broker 01 Name
- COMMERCE INSURANCE SERVICES, INC.
- Ins Broker 01 Street Addr
- 1701 ROUTE70 EAST, P.O. BOX 2060
- Ins Broker 01 City
- CHERRY HILL
- Ins Broker 01 State
- NJ
- Ins Broker 01 ZIP Code
- 08034
- Ins Broker Comm Pd 01 Amount
- $5,159
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 6
- Ins Carrier Name: SHENANDOAH LIFE INSURANCE COMPANY
- Filing Id
- 84037347325318
- Form Id
- 93408337
- Schedule A EIN
- 22-3032948
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- SHENANDOAH LIFE INSURANCE COMPANY
- Ins Carrier EIN
- 54-0377280
- Ins Carrier Naic Code
- 68845
- Ins Contract Num
- 0517770726
- Ins Prsn Covered End of year Count
- 585
- Ins Policy From Date
- 2007-01-01
- Ins Policy To Date
- 2007-12-31
- Ins Broker Comm Total Amount
- $33,068
- 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
- B
- 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
- $330,595
- Wlfr Acquis Cost Amount
- $0
- Row 7
- Ins Carrier Name: HARTFORD LIFE AND ACCIDENT
- Filing Id
- 84037347325318
- Form Id
- 93408334
- Schedule A EIN
- 22-3032948
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- HARTFORD LIFE AND ACCIDENT
- Ins Carrier EIN
- 06-0838648
- Ins Carrier Naic Code
- 70815
- Ins Contract Num
- 363225G
- Ins Prsn Covered End of year Count
- 246
- Ins Policy From Date
- 2007-01-01
- Ins Policy To Date
- 2007-12-31
- Ins Broker Comm Total Amount
- $5,047
- 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
- $62,996
- Wlfr Acquis Cost Amount
- $0
- Row 8
- Ins Carrier Name: HARTFORD LIFE AND ACCIDENT
- Filing Id
- 84037347325318
- Form Id
- 93408336
- Schedule A EIN
- 22-3032948
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- HARTFORD LIFE AND ACCIDENT
- Ins Carrier EIN
- 06-0838648
- Ins Carrier Naic Code
- 70815
- Ins Contract Num
- 361410G
- Ins Prsn Covered End of year Count
- 749
- Ins Policy From Date
- 2007-01-01
- Ins Policy To Date
- 2007-12-31
- Ins Broker Comm Total Amount
- $5,588
- 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
- $81,670
- Wlfr Acquis Cost Amount
- $0
- Row 9
- Ins Carrier Name: HARTFORD LIFE AND ACCIDENT
- Filing Id
- 84037347325318
- Form Id
- 93408335
- Schedule A EIN
- 22-3032948
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20070101
- Ins Carrier Name
- HARTFORD LIFE AND ACCIDENT
- Ins Carrier EIN
- 06-0838648
- Ins Carrier Naic Code
- 70815
- Ins Contract Num
- 361409G
- Ins Prsn Covered End of year Count
- 749
- Ins Policy From Date
- 2007-01-01
- Ins Policy To Date
- 2007-12-31
- Ins Broker Comm Total Amount
- $5,159
- 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
- $59,556
- Wlfr Acquis Cost Amount
- $0
- Row 10
- Ins Carrier Name: HLC
- Filing Id
- 84037347325318
- Form Id
- 93408338
- Schedule A EIN
- 22-3032948
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- HLC
- Ins Carrier EIN
- 06-1041332
- Ins Carrier Naic Code
- 93440
- Ins Contract Num
- EH300038
- Ins Prsn Covered End of year Count
- 748
- Ins Policy From Date
- 2007-01-01
- Ins Policy To Date
- 2007-12-31
- Ins Broker Comm Total Amount
- $59,088
- 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
- $393,921
- Wlfr Acquis Cost Amount
- $0