Schedule A
- Row 1
- Filing Id
- 84037009296794
- Form Id
- 44198941
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 2040374009296040004
- Ins Broker 01 Name
- FIRST VIRGINIA INS. SERVICES, INC.
- Ins Broker 01 Street Addr
- 6402 ARLINGTON BLVD.
- Ins Broker 01 City
- FALLS CHURCH
- Ins Broker 01 State
- VA
- Ins Broker 01 ZIP Code
- 22042
- Ins Broker Comm Pd 01 Amount
- $150
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 2
- Filing Id
- 84037009296794
- Form Id
- 44198942
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 2040374009296040005
- Ins Broker 01 Name
- EMPLOYEE BENEFITS CORP. OF AMERICA
- Ins Broker 01 Street Addr
- PO BOX 3528
- Ins Broker 01 City
- MCLEAN
- Ins Broker 01 State
- VA
- Ins Broker 01 ZIP Code
- 221033528
- Ins Broker Comm Pd 01 Amount
- $7,965
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 3
- Filing Id
- 84037009296794
- Form Id
- 44198943
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 2040374009296040006
- Ins Broker 01 Name
- JOHN EDWARD FOSTER
- Ins Broker 01 Street Addr
- 6550 ROCK SPRING DRIVE, STE 250
- Ins Broker 01 City
- BETHESDA
- Ins Broker 01 State
- MD
- Ins Broker 01 ZIP Code
- 20817
- Ins Broker Comm Pd 01 Amount
- $735
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 4
- Filing Id
- 84037009296794
- Form Id
- 44198944
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 2040374009296040007
- Ins Broker 01 Name
- YERGEY INSURANCE AGENCY
- Ins Broker 01 Street Addr
- 10550 LINDEN LAKE PLA&A, STE 100
- Ins Broker 01 City
- MANASSAS
- Ins Broker 01 State
- VA
- Ins Broker 01 ZIP Code
- 201090000
- Ins Broker Comm Pd 01 Amount
- $6,427
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 5
- Filing Id
- 84037009296794
- Form Id
- 44198939
- Page Id
- 1
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 2040374009296040002
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $0
- Row 6
- Filing Id
- 84037009296794
- Form Id
- 44198940
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 2040374009296040003
- Ins Broker 01 Name
- GROUP BENEFIT SERVICES
- Ins Broker 01 Street Addr
- 6 NORTH PARK DRIVE, STE 310
- Ins Broker 01 City
- HUNT VALLEY
- Ins Broker 01 State
- MD
- Ins Broker 01 ZIP Code
- 21030
- Ins Broker Comm Pd 01 Amount
- $53,956
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 7
- Filing Id
- 84037009296794
- Form Id
- 44198943
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 2
- Row Num
- 1
- Image Form Id
- 2040374009296040006
- Ins Broker 01 Name
- HOWARD SOLTOFF
- Ins Broker 01 Street Addr
- 6550 ROCK SPRING DRIVE, STE 250
- Ins Broker 01 City
- BETHESDA
- Ins Broker 01 State
- MD
- Ins Broker 01 ZIP Code
- 20817
- Ins Broker Comm Pd 01 Amount
- $735
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 8
- Filing Id
- 84037009296794
- Form Id
- 44198943
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 3
- Row Num
- 2
- Image Form Id
- 2040374009296040006
- Ins Broker 01 Name
- PAUL F LOVE
- Ins Broker 01 Street Addr
- 6550 ROCK SPRING DRIVE, STE 250
- Ins Broker 01 City
- BETHESDA
- Ins Broker 01 State
- MD
- Ins Broker 01 ZIP Code
- 20817
- Ins Broker Comm Pd 01 Amount
- $735
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 9
- Ins Carrier Name: HIGHMARK LIFE INSURANCE CO.
- Filing Id
- 84037009296794
- Form Id
- 44198943
- Schedule A EIN
- 54-1441003
- Schedule A Plan Num
- 510
- Schedule A Plan Year Begin Date
- 2002-01-01
- Schedule A Tax Period
- 20021231
- Ins Carrier Name
- HIGHMARK LIFE INSURANCE CO.
- Ins Carrier EIN
- 06-1041332
- Ins Carrier Naic Code
- 93440
- Ins Contract Num
- 9069980010
- Ins Prsn Covered End of year Count
- 19
- Ins Policy From Date
- 2001-05-01
- Ins Policy To Date
- 2002-04-30
- Ins Broker Comm Total Amount
- $2,205
- 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
- DM
- Wlfr Type Bnft Oth Text
- VOL AD&D, VOL DEP & SPOUSE LIFE INS
- 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
- $11,021
- Wlfr Acquis Cost Amount
- $0
- Row 10
- Ins Carrier Name: ASSOCIATION & SOCIETY INSURANCE CORPORATION
- Filing Id
- 84037009296794
- Form Id
- 44198939
- Schedule A EIN
- 54-1441003
- Schedule A Plan Num
- 510
- Schedule A Plan Year Begin Date
- 2002-01-01
- Schedule A Tax Period
- 20021231
- Ins Carrier Name
- ASSOCIATION & SOCIETY INSURANCE CORPORATION
- Ins Carrier EIN
- 06-0974148
- Ins Carrier Naic Code
- 88072
- Ins Contract Num
- 341.2
- Ins Prsn Covered End of year Count
- 21
- Ins Policy From Date
- 2002-01-01
- Ins Policy To Date
- 2002-12-31
- 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
- CDGKM
- Wlfr Type Bnft Oth Text
- TRICARE/CHAMPUS
- 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
- $36,159
- Wlfr Acquis Cost Amount
- $0
- Row 11
- Ins Carrier Name: FEDERAL INSURANCE COMPANY
- Filing Id
- 84037009296794
- Form Id
- 44198941
- Schedule A EIN
- 54-1441003
- Schedule A Plan Num
- 510
- Schedule A Plan Year Begin Date
- 2002-01-01
- Schedule A Tax Period
- 20021231
- Ins Carrier Name
- FEDERAL INSURANCE COMPANY
- Ins Carrier EIN
- 13-1963496
- Ins Carrier Naic Code
- 20281
- Ins Contract Num
- 64084397
- Ins Prsn Covered End of year Count
- 460
- Ins Policy From Date
- 2001-12-15
- Ins Policy To Date
- 2002-12-15
- Ins Broker Comm Total Amount
- $150
- 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
- CDGKM
- Wlfr Type Bnft Oth Text
- BUSINESS TRAVEL ACCIDE=T
- 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
- $1,000
- Wlfr Acquis Cost Amount
- $0
- Row 12
- Ins Carrier Name: SHENANDOAH LIFE INSURANCE COMPANY
- Filing Id
- 84037009296794
- Form Id
- 44198944
- Schedule A EIN
- 54-1441003
- Schedule A Plan Num
- 510
- Schedule A Plan Year Begin Date
- 2002-01-01
- Schedule A Tax Period
- 20021231
- Ins Carrier Name
- SHENANDOAH LIFE INSURANCE COMPANY
- Ins Carrier EIN
- 54-0377280
- Ins Carrier Naic Code
- 68845
- Ins Contract Num
- 0070041619
- Ins Prsn Covered End of year Count
- 319
- Ins Policy From Date
- 2001-02-01
- Ins Policy To Date
- 2002-01-31
- Ins Broker Comm Total Amount
- $6,427
- 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
- BDM
- Wlfr Type Bnft Oth Text
- AD&D
- Wlfr Premium Rcvd Amount
- $0
- Wlfr Unpaid Due Amount
- $0
- Wlfr Reserve Amount
- $0
- Wlfr Total Earned Prem Amount
- $0
- Wlfr Claims Paid Amount
- $0
- Wlfr Incr Reserve Amount
- $0
- Wlfr Incurred Claim Amount
- $0
- Wlfr Claims Chrgd Amount
- $0
- Wlfr Ret Commissions Amount
- $0
- Wlfr Ret Admin Amount
- $0
- Wlfr Ret Oth Cost Amount
- $0
- Wlfr Ret Oth Expense Amount
- $0
- Wlfr Ret Taxes Amount
- $0
- Wlfr Ret Charges Amount
- $0
- Wlfr Ret Oth Chrgs Amount
- $0
- Wlfr Ret Total Amount
- $0
- Wlfr Refund Amount
- $0
- Wlfr Held Bnfts Amount
- $0
- Wlfr Claims Reserve Amount
- $0
- Wlfr Oth Reserve Amount
- $0
- Wlfr Divnds Due Amount
- $0
- Wlfr Total Charges Paid Amount
- $197,872
- Wlfr Acquis Cost Amount
- $0
- Row 13
- Ins Carrier Name: CAREFIRST, INC.
- Filing Id
- 84037009296794
- Form Id
- 44198940
- Schedule A EIN
- 54-1441003
- Schedule A Plan Num
- 510
- Schedule A Plan Year Begin Date
- 2002-01-01
- Schedule A Tax Period
- 20021231
- Ins Carrier Name
- CAREFIRST, INC.
- Ins Carrier EIN
- 53-0078070
- Ins Carrier Naic Code
- 53007
- Ins Contract Num
- WE99
- Ins Prsn Covered End of year Count
- 157
- Ins Policy From Date
- 2001-02-01
- Ins Policy To Date
- 2002-01-31
- Ins Broker Comm Total Amount
- $53,956
- Ins Broker Fees Total Amount
- $0
- Pension End of year Gen Account Amount
- $0
- Pension End of year Sep Account Amount
- $0
- Pension Prem Paid Total Amount
- $0
- Pension Unpaid Premium Amount
- $0
- Pension Contract Cost Amount
- $0
- Pension End Prev Bal Amount
- $0
- Pension Contribution Dep Amount
- $0
- Pension Divnd Cr Dep Amount
- $0
- Pension Interest Cr Dur Yr Amount
- $0
- Pension Transfer From Amount
- $0
- Pension Other Amount
- $0
- Pension Total Additions Amount
- $0
- Pension Total Bal Addn Amount
- $0
- Pension Bnfts Dsbrsd Amount
- $0
- Pension Admin Chrg Amount
- $0
- Pension Transfer To Amount
- $0
- Pension Oth Ded Amount
- $0
- Pension Total Ded Amount
- $0
- Pension End of year Bal Amount
- $0
- Wlfr Type Bnft Indicator
- A
- Wlfr Premium Rcvd Amount
- $0
- Wlfr Unpaid Due Amount
- $0
- Wlfr Reserve Amount
- $0
- Wlfr Total Earned Prem Amount
- $0
- Wlfr Claims Paid Amount
- $0
- Wlfr Incr Reserve Amount
- $0
- Wlfr Incurred Claim Amount
- $0
- Wlfr Claims Chrgd Amount
- $0
- Wlfr Ret Commissions Amount
- $0
- Wlfr Ret Admin Amount
- $0
- Wlfr Ret Oth Cost Amount
- $0
- Wlfr Ret Oth Expense Amount
- $0
- Wlfr Ret Taxes Amount
- $0
- Wlfr Ret Charges Amount
- $0
- Wlfr Ret Oth Chrgs Amount
- $0
- Wlfr Ret Total Amount
- $0
- Wlfr Refund Amount
- $0
- Wlfr Held Bnfts Amount
- $0
- Wlfr Claims Reserve Amount
- $0
- Wlfr Oth Reserve Amount
- $0
- Wlfr Divnds Due Amount
- $0
- Wlfr Total Charges Paid Amount
- $1,079,118
- Wlfr Acquis Cost Amount
- $0
- Row 14
- Ins Carrier Name: HARTFORD LIFE AND ACCIDENT
- Filing Id
- 84037009296794
- Form Id
- 44198942
- Schedule A EIN
- 54-1441003
- Schedule A Plan Num
- 510
- Schedule A Plan Year Begin Date
- 2002-01-01
- Schedule A Tax Period
- 20021231
- Ins Carrier Name
- HARTFORD LIFE AND ACCIDENT
- Ins Carrier EIN
- 06-0838648
- Ins Carrier Naic Code
- 70815
- Ins Contract Num
- GLT/GRH 704634
- Ins Prsn Covered End of year Count
- 273
- Ins Policy From Date
- 2002-01-01
- Ins Policy To Date
- 2002-12-31
- Ins Broker Comm Total Amount
- $7,965
- 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
- EFM
- Wlfr Type Bnft Oth Text
- WD-NST
- 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
- $89,914
- Wlfr Acquis Cost Amount
- $0