Schedule A
- Row 1
- Filing Id
- 91037119292882
- Form Id
- 14990202
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 10372093277020002
- Ins Broker 01 Name
- FOSTER SOLTOFF & LOVE LTD
- Ins Broker 01 Street Addr
- 6550 ROCK SPRING DRIVE
- Ins Broker 01 City
- BETHESDA
- Ins Broker 01 State
- MD
- Ins Broker 01 ZIP Code
- 20817
- Ins Broker Comm Pd 01 Amount
- $3,893
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 2
- Filing Id
- 91037119292882
- Form Id
- 14990204
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 10372093277020004
- Ins Broker 01 Name
- FIRST VIRGINIA INSURANCE 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
- $1,640
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 3
- Filing Id
- 91037119292882
- Form Id
- 14990205
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 10372093277020005
- Ins Broker 01 Name
- FIRST VIRGINIA INSURANCE 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
- $255
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 4
- Filing Id
- 91037119292882
- Form Id
- 14990206
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 10372093277020006
- Ins Broker 01 Name
- FOSTER SOLTOFF & LOVE LTD
- Ins Broker 01 Street Addr
- 6550 ROCK SPRING DR, STE 250
- Ins Broker 01 City
- BETHESDA
- Ins Broker 01 State
- MD
- Ins Broker 01 ZIP Code
- 20817
- Ins Broker Comm Pd 01 Amount
- $8,249
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 5
- Filing Id
- 91037119292882
- Form Id
- 14990203
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 10372093277020003
- Ins Broker 01 Name
- FOSTER SOLTOFF & LOVE LTD
- Ins Broker 01 Street Addr
- 6550 ROCK SPRING DR STE 250
- Ins Broker 01 City
- BETHESDA
- Ins Broker 01 State
- MD
- Ins Broker 01 ZIP Code
- 20817
- Ins Broker Comm Pd 01 Amount
- $1,329
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 6
- Ins Carrier Name: AMERITAS LIFE INSURANCE CORP
- Filing Id
- 91037119292882
- Form Id
- 14990203
- Schedule A EIN
- 54-1441003
- Schedule A Plan Num
- 510
- Schedule A Plan Year Begin Date
- 2000-01-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- AMERITAS LIFE INSURANCE CORP
- Ins Carrier EIN
- 47-0098400
- Ins Carrier Naic Code
- 61301
- Ins Contract Num
- 01021076
- Ins Prsn Covered End of year Count
- 292
- Ins Broker Comm Total Amount
- $1,329
- 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
- $29,618
- Wlfr Acquis Cost Amount
- $0
- Row 7
- Ins Carrier Name: CIGNA
- Filing Id
- 91037119292882
- Form Id
- 14990204
- Schedule A EIN
- 54-1441003
- Schedule A Plan Num
- 510
- Schedule A Plan Year Begin Date
- 2000-01-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- CIGNA
- Ins Carrier EIN
- 06-0303370
- Ins Carrier Naic Code
- 62308
- Ins Contract Num
- DE6129
- Ins Prsn Covered End of year Count
- 5
- Ins Policy From Date
- 1999-09-07
- Ins Policy To Date
- 2000-09-06
- Ins Broker Comm Total Amount
- $1,640
- 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
- ABE
- 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
- $20,502
- Wlfr Acquis Cost Amount
- $0
- Row 8
- Ins Carrier Name: CIGNA
- Filing Id
- 91037119292882
- Form Id
- 14990205
- Schedule A EIN
- 54-1441003
- Schedule A Plan Num
- 510
- Schedule A Plan Year Begin Date
- 2000-01-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- CIGNA
- Ins Carrier EIN
- 23-2088429
- Ins Carrier Naic Code
- 90859
- Ins Contract Num
- DE6129
- Ins Prsn Covered End of year Count
- 5
- Ins Policy From Date
- 1999-09-07
- Ins Policy To Date
- 2000-09-06
- Ins Broker Comm Total Amount
- $255
- 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
- $3,193
- Wlfr Acquis Cost Amount
- $0
- Row 9
- Ins Carrier Name: UNUM LIFE INSURANCE COMPANY OF AMERICA
- Filing Id
- 91037119292882
- Form Id
- 14990206
- Schedule A EIN
- 54-1441003
- Schedule A Plan Num
- 510
- Schedule A Plan Year Begin Date
- 2000-01-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- UNUM LIFE INSURANCE COMPANY OF AMERICA
- Ins Carrier EIN
- 01-0278678
- Ins Carrier Naic Code
- 62235
- Ins Contract Num
- 376424
- Ins Prsn Covered End of year Count
- 330
- Ins Policy From Date
- 1999-06-15
- Ins Policy To Date
- 2000-06-15
- Ins Broker Comm Total Amount
- $8,249
- 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
- ACCIDENTAL DEATH AND DISMEMBERMENT
- 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
- $132,416
- Wlfr Acquis Cost Amount
- $0
- Row 10
- Ins Carrier Name: TRUSTMARK INSURANCE COMPANY
- Filing Id
- 91037119292882
- Form Id
- 14990202
- Schedule A EIN
- 54-1441003
- Schedule A Plan Num
- 510
- Schedule A Plan Year Begin Date
- 2000-01-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- TRUSTMARK INSURANCE COMPANY
- Ins Carrier EIN
- 36-0792925
- Ins Carrier Naic Code
- 61425
- Ins Contract Num
- EV518
- Ins Prsn Covered End of year Count
- 366
- Ins Policy From Date
- 2000-01-01
- Ins Policy To Date
- 2000-02-01
- Ins Broker Comm Total Amount
- $3,893
- 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
- ADHKM
- Wlfr Type Bnft Oth Text
- ACCIDENTAL DEATH AND DISMEMBERMENT
- 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
- $77,862
- Wlfr Acquis Cost Amount
- $0