Schedule A
- Row 1
- Filing Id
- 84037175354034
- Form Id
- 47229189
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3010374175354030006
- Ins Broker 01 Name
- GAYLE T. MILTON
- Ins Broker 01 Street Addr
- 200 WEST SIDE SQUARE, STE 52
- Ins Broker 01 City
- HUNTSVILLE
- Ins Broker 01 State
- AL
- Ins Broker 01 ZIP Code
- 35801
- Ins Broker Comm Pd 01 Amount
- $6,541
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 2
- Filing Id
- 84037175354034
- Form Id
- 47229185
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3010374175354030002
- Ins Broker 01 Name
- GAYLE MILTON
- Ins Broker 01 Street Addr
- 200 WEST SIDE SQUARE
- Ins Broker 01 City
- HUNTSVILLE
- Ins Broker 01 State
- AL
- Ins Broker 01 ZIP Code
- 35801
- Ins Broker Comm Pd 01 Amount
- $9,225
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 3
- Filing Id
- 84037175354034
- Form Id
- 47229186
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3010374175354030003
- Ins Broker 01 Name
- GAYLE T. MILTON
- Ins Broker 01 Street Addr
- 3131 MAPLE DRIVE
- Ins Broker 01 City
- ATLANTA
- Ins Broker 01 State
- GA
- Ins Broker 01 ZIP Code
- 30305
- Ins Broker Comm Pd 01 Amount
- $7,043
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 4
- Filing Id
- 84037175354034
- Form Id
- 47229187
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3010374175354030004
- Ins Broker 01 Name
- GAYLE T. MILTON
- Ins Broker 01 Street Addr
- 200 WEST SIDE SQUARE, SUITE 52
- Ins Broker 01 City
- HUNTSVILLE
- Ins Broker 01 State
- AL
- Ins Broker 01 ZIP Code
- 35801
- Ins Broker Comm Pd 01 Amount
- $641
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 5
- Filing Id
- 84037175354034
- Form Id
- 47229188
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3010374175354030005
- Ins Broker 01 Name
- GAYLE T. MILTON
- Ins Broker 01 Street Addr
- 200 WEST SIDE SQUARE, SUITE 52
- Ins Broker 01 City
- HUNTSVILLE
- Ins Broker 01 State
- AL
- Ins Broker 01 ZIP Code
- 35801
- Ins Broker Comm Pd 01 Amount
- $4,574
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 6
- Filing Id
- 84037175354034
- Form Id
- 47229187
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 2
- Row Num
- 1
- Image Form Id
- 3010374175354030004
- Ins Broker 01 Name
- JOSEPH S. LAWRENCE
- Ins Broker 01 Street Addr
- 2309 STARMOUNT CIRCLE
- Ins Broker 01 City
- HUNTSVILLE
- Ins Broker 01 State
- AL
- Ins Broker 01 ZIP Code
- 35801
- Ins Broker Comm Pd 01 Amount
- $641
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 7
- Ins Carrier Name: UNITED HEALTH CARE OF TENNESSEE
- Filing Id
- 84037175354034
- Form Id
- 47229185
- Schedule A EIN
- 63-1004214
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20030413
- Ins Carrier Name
- UNITED HEALTH CARE OF TENNESSEE
- Ins Carrier EIN
- 63-1036814
- Ins Carrier Naic Code
- 06324
- Ins Contract Num
- 104996
- Ins Prsn Covered End of year Count
- 167
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-04-13
- Ins Broker Comm Total Amount
- $9,225
- 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
- $358,742
- Wlfr Acquis Cost Amount
- $0
- Row 8
- Ins Carrier Name: UNUM LIFE INSURANCE COMPANY OF AMERICA
- Filing Id
- 84037175354034
- Form Id
- 47229187
- Schedule A EIN
- 63-1004214
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20030413
- Ins Carrier Name
- UNUM LIFE INSURANCE COMPANY OF AMERICA
- Ins Carrier EIN
- 01-0278678
- Ins Carrier Naic Code
- 62235
- Ins Contract Num
- 555274
- Ins Prsn Covered End of year Count
- 912
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-04-13
- Ins Broker Comm Total Amount
- $1,282
- 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
- $14,244
- Wlfr Acquis Cost Amount
- $0
- Row 9
- Ins Carrier Name: THE GUARDIAN INSURANCE COMPANY OF AMERICA
- Filing Id
- 84037175354034
- Form Id
- 47229188
- Schedule A EIN
- 63-1004214
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20030413
- Ins Carrier Name
- THE GUARDIAN INSURANCE COMPANY OF AMERICA
- Ins Carrier EIN
- 13-5123390
- Ins Carrier Naic Code
- 64246
- Ins Contract Num
- 363804
- Ins Prsn Covered End of year Count
- 731
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-04-13
- Ins Broker Comm Total Amount
- $4,574
- 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
- $91,485
- Wlfr Acquis Cost Amount
- $0
- Row 10
- Ins Carrier Name: THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA
- Filing Id
- 84037175354034
- Form Id
- 47229189
- Schedule A EIN
- 63-1004214
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20030413
- Ins Carrier Name
- THE GUARDIAN LIFE INSURANCE COMPANY OF AMERICA
- Ins Carrier EIN
- 13-5123390
- Ins Carrier Naic Code
- 64246
- Ins Contract Num
- 364021
- Ins Prsn Covered End of year Count
- 905
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-04-13
- Ins Broker Comm Total Amount
- $6,541
- 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
- OPT. LIFE
- 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
- $49,740
- Wlfr Acquis Cost Amount
- $0
- Row 11
- Ins Carrier Name: THE GUARDIAN LIFE INSURANCE COMPANY
- Filing Id
- 84037175354034
- Form Id
- 47229186
- Schedule A EIN
- 63-1004214
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20030413
- Ins Carrier Name
- THE GUARDIAN LIFE INSURANCE COMPANY
- Ins Carrier EIN
- 13-5123390
- Ins Carrier Naic Code
- 64246
- Ins Contract Num
- 354507
- Ins Prsn Covered End of year Count
- 435
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-04-13
- Ins Broker Comm Total Amount
- $7,043
- 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
- E
- 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
- $46,956
- Wlfr Acquis Cost Amount
- $0