Schedule A
- Row 1
- Filing Id
- 56037130047311
- Form Id
- 4774622
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 20371130047060007
- Ins Broker 01 Name
- WILLIS TEXAS
- Ins Broker 01 Street Addr
- 301 COMMERCE AVE
- Ins Broker 01 City
- FT WORTH
- Ins Broker 01 State
- TX
- Ins Broker 01 ZIP Code
- 76102
- Ins Broker Comm Pd 01 Amount
- $8,972
- Ins Broker Fees Pd 01 Amount
- $0
- Row 2
- Filing Id
- 56037130047311
- Form Id
- 4774619
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 20371130047060004
- Ins Broker 01 Name
- WILLIS CORROON LIFE INS
- Ins Broker 01 Street Addr
- P O BOX 73075
- Ins Broker 01 City
- DALLAS
- Ins Broker 01 State
- TX
- Ins Broker 01 ZIP Code
- 75373
- Ins Broker Comm Pd 01 Amount
- $15,908
- Ins Broker Fees Pd 01 Amount
- $0
- Row 3
- Filing Id
- 56037130047311
- Form Id
- 4774617
- Page Id
- 1
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 20371130047060002
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $0
- Row 4
- Filing Id
- 56037130047311
- Form Id
- 4774618
- Page Id
- 1
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 20371130047060003
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $0
- Row 5
- Filing Id
- 56037130047311
- Form Id
- 4774620
- Page Id
- 1
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 20371130047060005
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $0
- Row 6
- Filing Id
- 56037130047311
- Form Id
- 4774621
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 20371130047060006
- Ins Broker 01 Name
- WILLIS OF TEXAS
- Ins Broker 01 Street Addr
- 301 COMMERCE AVE
- Ins Broker 01 City
- HOUSTON
- Ins Broker 01 State
- TX
- Ins Broker 01 ZIP Code
- 76102
- Ins Broker Comm Pd 01 Amount
- $2,282
- Ins Broker Fees Pd 01 Amount
- $0
- Row 7
- Ins Carrier Name: BC BS OF HIGHMARK
- Filing Id
- 56037130047311
- Form Id
- 4774617
- Schedule A EIN
- 22-3473702
- Schedule A Plan Num
- 524
- Schedule A Plan Year Begin Date
- 1999-09-30
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- BC BS OF HIGHMARK
- Ins Contract Num
- 46267
- Ins Prsn Covered End of year Count
- 1,639
- Ins Policy From Date
- 1999-09-30
- Ins Policy To Date
- 1999-12-31
- 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
- AD
- Wlfr Premium Rcvd Amount
- $336,599
- Wlfr Unpaid Due Amount
- $0
- Wlfr Reserve Amount
- $0
- Wlfr Total Earned Prem Amount
- $336,599
- Wlfr Claims Paid Amount
- $276,351
- Wlfr Incr Reserve Amount
- $0
- Wlfr Incurred Claim Amount
- $276,351
- 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
- $8,950
- Wlfr Ret Total Amount
- $8,950
- Wlfr Refund Amount
- $0
- Wlfr Held Bnfts Amount
- $0
- Wlfr Claims Reserve Amount
- $45,600
- Wlfr Oth Reserve Amount
- $0
- Wlfr Divnds Due Amount
- $0
- Wlfr Total Charges Paid Amount
- $0
- Wlfr Acquis Cost Amount
- $0
- Row 8
- Ins Carrier Name: CONNECTICUT GENERAL LIFE INS
- Filing Id
- 56037130047311
- Form Id
- 4774618
- Schedule A EIN
- 22-3473702
- Schedule A Plan Num
- 524
- Schedule A Plan Year Begin Date
- 1999-09-30
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- CONNECTICUT GENERAL LIFE INS
- Ins Contract Num
- 2373970
- Ins Prsn Covered End of year Count
- 3,485
- Ins Policy From Date
- 1999-09-30
- Ins Policy To Date
- 1999-12-31
- 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
- DE
- 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
- $184,341
- Wlfr Acquis Cost Amount
- $0
- Row 9
- Ins Carrier Name: PROVIDENT LIFE INS
- Filing Id
- 56037130047311
- Form Id
- 4774619
- Schedule A EIN
- 22-3473702
- Schedule A Plan Num
- 524
- Schedule A Plan Year Begin Date
- 1999-09-30
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- PROVIDENT LIFE INS
- Ins Contract Num
- 123235
- Ins Prsn Covered End of year Count
- 2,188
- Ins Policy From Date
- 1999-09-30
- Ins Policy To Date
- 1999-12-31
- Ins Broker Comm Total Amount
- $15,908
- 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
- $159,084
- Wlfr Acquis Cost Amount
- $0
- Row 10
- Ins Carrier Name: UNITED HEALTHCARE
- Filing Id
- 56037130047311
- Form Id
- 4774620
- Schedule A EIN
- 22-3473702
- Schedule A Plan Num
- 524
- Schedule A Plan Year Begin Date
- 1999-09-30
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- UNITED HEALTHCARE
- Ins Contract Num
- 209405
- Ins Prsn Covered End of year Count
- 11,833
- Ins Policy From Date
- 1999-09-30
- Ins Policy To Date
- 1999-12-31
- 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
- $3,575,994
- Wlfr Unpaid Due Amount
- $0
- Wlfr Reserve Amount
- $0
- Wlfr Total Earned Prem Amount
- $3,575,994
- 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
- $974,524
- 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
- $974,524
- 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
- $111,232
- Wlfr Acquis Cost Amount
- $0
- Row 11
- Filing Id
- 56037130047311
- Form Id
- 4774621
- Schedule A EIN
- 22-3473702
- Schedule A Plan Year Begin Date
- 1999-09-30
- Schedule A Tax Period
- 19991231
- 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
- $0
- Wlfr Acquis Cost Amount
- $0
- Row 12
- Ins Carrier Name: ZURICH
- Filing Id
- 56037130047311
- Form Id
- 4774622
- Schedule A EIN
- 22-3473702
- Schedule A Plan Num
- 524
- Schedule A Plan Year Begin Date
- 1999-09-30
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- ZURICH
- Ins Contract Num
- GTU3586807
- Ins Prsn Covered End of year Count
- 12,822
- Ins Policy From Date
- 1999-09-30
- Ins Policy To Date
- 1999-12-31
- Ins Broker Comm Total Amount
- $8,972
- 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
- $89,716
- Wlfr Acquis Cost Amount
- $0