Schedule A
- Row 1
- Filing Id
- 84037232578048
- Form Id
- 89397989
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7010378232578040009
- Ins Broker 01 Name
- USI INSURANCE SERVICES OF FLORIDA
- Ins Broker 01 Street Addr
- 200 WEST CYPRESS CREEK ROAD
- Ins Broker 01 City
- FORT LAUDERDALE
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33309
- Ins Broker Comm Pd 01 Amount
- $3,091
- Ins Broker Fees Pd 01 Amount
- $667
- Ins Broker Fees Pd 01 Text
- SALES AND SERVICE
- Ins Broker 01 Code
- 3
- Row 2
- Filing Id
- 84037232578048
- Form Id
- 89397982
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7010378232578040002
- Ins Broker 01 Name
- USI INSURANCE SERVICES OF FLORIDA
- Ins Broker 01 Street Addr
- 200 WEST CYPRESS CREEK ROAD
- Ins Broker 01 City
- FORT LAUDERDALE
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33309
- Ins Broker Comm Pd 01 Amount
- $9,059
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Text
- SALES AND SERVICE
- Ins Broker 01 Code
- 3
- Row 3
- Filing Id
- 84037232578048
- Form Id
- 89397983
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7010378232578040003
- Ins Broker 01 Name
- USI INSURANCE SERVICES OF FLORIDA
- Ins Broker 01 Street Addr
- 200 WEST CYPRESS CREEK ROAD
- Ins Broker 01 City
- FORT LAUDERDALE
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33309
- Ins Broker Comm Pd 01 Amount
- $11,683
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Text
- SALES AND SERVICE
- Ins Broker 01 Code
- 3
- Row 4
- Filing Id
- 84037232578048
- Form Id
- 89397984
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7010378232578040004
- Ins Broker 01 Name
- USI INSURANCE SERVICES OF FLORIDA
- Ins Broker 01 Street Addr
- 200 WEST CYPRESS CREEK ROAD
- Ins Broker 01 City
- FORT LAUDERDALE
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33309
- Ins Broker Comm Pd 01 Amount
- $8,427
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Text
- SALES AND SERVICE
- Ins Broker 01 Code
- 3
- Row 5
- Filing Id
- 84037232578048
- Form Id
- 89397985
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7010378232578040005
- Ins Broker 01 Name
- USI INSURANCE SERVICES OF FLORIDA
- Ins Broker 01 Street Addr
- 200 WEST CYPRESS CREEK ROAD
- Ins Broker 01 City
- FORT LAUDERDALE
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33309
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Text
- SALES AND SERVICE
- Ins Broker 01 Code
- 3
- Row 6
- Filing Id
- 84037232578048
- Form Id
- 89397986
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7010378232578040006
- Ins Broker 01 Name
- USI INSURANCE SERVICES OF FLORIDA
- Ins Broker 01 Street Addr
- 200 WEST CYPRESS CREEK ROAD
- Ins Broker 01 City
- FORT LAUDERDALE
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33309
- Ins Broker Comm Pd 01 Amount
- $3,339
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Text
- SALES AND SERVICE
- Ins Broker 01 Code
- 3
- Row 7
- Filing Id
- 84037232578048
- Form Id
- 89397987
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7010378232578040007
- Ins Broker 01 Name
- USI INSURANCE SERVICES OF FLORIDA
- Ins Broker 01 Street Addr
- 200 WEST CYPRESS CREEK ROAD
- Ins Broker 01 City
- FORT LAUDERDALE
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33309
- Ins Broker Comm Pd 01 Amount
- $47,237
- Ins Broker Fees Pd 01 Amount
- $1,792
- Ins Broker Fees Pd 01 Text
- SALES AND SERVICE
- Ins Broker 01 Code
- 3
- Row 8
- Filing Id
- 84037232578048
- Form Id
- 89397988
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 7010378232578040008
- Ins Broker 01 Name
- USI INSURANCE SERVICES OF FLORIDA
- Ins Broker 01 Street Addr
- 200 WEST CYPRESS CREEK ROAD
- Ins Broker 01 City
- FORT LAUDERDALE
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33309
- Ins Broker Comm Pd 01 Amount
- $4,710
- Ins Broker Fees Pd 01 Amount
- $1,157
- Ins Broker Fees Pd 01 Text
- SALES AND SERVICE
- Ins Broker 01 Code
- 3
- Row 9
- Ins Carrier Name: AETNA LIFE INSURANCE COMPANY
- Filing Id
- 84037232578048
- Form Id
- 89397982
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- AETNA LIFE INSURANCE COMPANY
- Ins Carrier EIN
- 06-6033492
- Ins Carrier Naic Code
- 95003
- Ins Contract Num
- 500259
- Ins Prsn Covered End of year Count
- 243
- Ins Policy From Date
- 2006-11-01
- Ins Policy To Date
- 2007-10-31
- Ins Broker Comm Total Amount
- $9,059
- 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
- ABCDE
- 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
- $171,330
- Wlfr Acquis Cost Amount
- $0
- Row 10
- Ins Carrier Name: COMMUNITY CARE HMO
- Filing Id
- 84037232578048
- Form Id
- 89397983
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- COMMUNITY CARE HMO
- Ins Carrier EIN
- 73-1433979
- Ins Carrier Naic Code
- 10001
- Ins Contract Num
- SA1101
- Ins Prsn Covered End of year Count
- 67
- Ins Policy From Date
- 2006-11-01
- Ins Policy To Date
- 2007-10-31
- Ins Broker Comm Total Amount
- $11,683
- 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
- J
- 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
- $256,425
- Wlfr Acquis Cost Amount
- $0
- Row 11
- Ins Carrier Name: COMPBENEFITS COMPANY
- Filing Id
- 84037232578048
- Form Id
- 89397984
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- COMPBENEFITS COMPANY
- Ins Carrier EIN
- 59-2531815
- Ins Carrier Naic Code
- 52015
- Ins Contract Num
- 57600/F57600
- Ins Prsn Covered End of year Count
- 380
- Ins Policy From Date
- 2006-11-01
- Ins Policy To Date
- 2007-10-31
- Ins Broker Comm Total Amount
- $8,427
- 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
- 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
- $79,505
- Wlfr Acquis Cost Amount
- $0
- Row 12
- Ins Carrier Name: EYEMED VISION CARE
- Filing Id
- 84037232578048
- Form Id
- 89397985
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- EYEMED VISION CARE
- Ins Carrier EIN
- 43-0949844
- Ins Carrier Naic Code
- 71870
- Ins Contract Num
- 9683178
- Ins Prsn Covered End of year Count
- 432
- Ins Policy From Date
- 2006-11-01
- Ins Policy To Date
- 2007-10-31
- 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
- C
- 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
- $17,682
- Wlfr Acquis Cost Amount
- $0
- Row 13
- Ins Carrier Name: HUMANA HEALTH COMPANY OF FLORIDA
- Filing Id
- 84037232578048
- Form Id
- 89397986
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- HUMANA HEALTH COMPANY OF FLORIDA
- Ins Carrier EIN
- 61-1041514
- Ins Carrier Naic Code
- 69671
- Ins Contract Num
- 806630
- Ins Prsn Covered End of year Count
- 9
- Ins Policy From Date
- 2006-11-01
- Ins Policy To Date
- 2007-10-31
- Ins Broker Comm Total Amount
- $3,339
- 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
- $132,588
- Wlfr Acquis Cost Amount
- $0
- Row 14
- Ins Carrier Name: HUMANA MEDICAL PLAN, INC
- Filing Id
- 84037232578048
- Form Id
- 89397987
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- HUMANA MEDICAL PLAN, INC
- Ins Carrier EIN
- 61-1103898
- Ins Carrier Naic Code
- 95270
- Ins Contract Num
- M5146
- Ins Prsn Covered End of year Count
- 189
- Ins Policy From Date
- 2006-11-01
- Ins Policy To Date
- 2007-10-31
- Ins Broker Comm Total Amount
- $47,237
- Ins Broker Fees Total Amount
- $1,792
- 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
- $888,072
- Wlfr Acquis Cost Amount
- $0
- Row 15
- Ins Carrier Name: LINCOLN NATIONAL LIFE INSURANCE COMPANY
- Filing Id
- 84037232578048
- Form Id
- 89397989
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- LINCOLN NATIONAL LIFE INSURANCE COMPANY
- Ins Carrier EIN
- 35-0472300
- Ins Carrier Naic Code
- 70254
- Ins Contract Num
- 40000100003992
- Ins Prsn Covered End of year Count
- 114
- Ins Policy From Date
- 2006-11-01
- Ins Policy To Date
- 2007-10-31
- Ins Broker Comm Total Amount
- $3,091
- Ins Broker Fees Total Amount
- $667
- 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
- 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
- $20,611
- Wlfr Acquis Cost Amount
- $0
- Row 16
- Ins Carrier Name: LINCOLN NATIONAL LIFE INSURANCE COMPANY
- Filing Id
- 84037232578048
- Form Id
- 89397988
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2007-01-01
- Schedule A Tax Period
- 20071231
- Ins Carrier Name
- LINCOLN NATIONAL LIFE INSURANCE COMPANY
- Ins Carrier EIN
- 35-0472300
- Ins Carrier Naic Code
- 70254
- Ins Contract Num
- 10064762
- Ins Prsn Covered End of year Count
- 375
- Ins Policy From Date
- 2006-11-01
- Ins Policy To Date
- 2007-10-31
- Ins Broker Comm Total Amount
- $4,710
- Ins Broker Fees Total Amount
- $1,157
- 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
- DF
- 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
- $31,407
- Wlfr Acquis Cost Amount
- $0