Schedule A
- Row 1
- Filing Id
- 84037237383566
- Form Id
- 71267772
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 5030376237383060008
- Ins Broker 01 Name
- SUMMIT GLOBAL PARTNERS OF FLORIDA
- Ins Broker 01 Street Addr
- 3651 FAU BOULEVARD
- Ins Broker 01 City
- BOCA RATON
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33431
- Ins Broker Comm Pd 01 Amount
- $786
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Text
- SALES AND SERVICE
- Ins Broker 01 Code
- 3
- Row 2
- Filing Id
- 84037237383566
- Form Id
- 71267773
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 5030376237383060009
- Ins Broker 01 Name
- SUMMIT GLOBAL PARTNERS OF FLORIDA
- Ins Broker 01 Street Addr
- 3651 FAU BOULEVARD
- Ins Broker 01 City
- BOCA RATON
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33431
- Ins Broker Comm Pd 01 Amount
- $3,242
- 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
- 84037237383566
- Form Id
- 71267768
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 5030376237383060004
- Ins Broker 01 Name
- SUMMIT GLOBAL PARTNERS OF FLORIDA
- Ins Broker 01 Street Addr
- 3651 FAU BOULEVARD
- Ins Broker 01 City
- BOCA RATON
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33431
- Ins Broker Comm Pd 01 Amount
- $6,659
- 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
- 84037237383566
- Form Id
- 71267771
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 5030376237383060007
- Ins Broker 01 Name
- SUMMIT GLOBAL PARTNERS OF FLORIDA
- Ins Broker 01 Street Addr
- 3651 FAU BOULEVARD
- Ins Broker 01 City
- BOCA RATON
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33431
- Ins Broker Comm Pd 01 Amount
- $9
- 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
- 84037237383566
- Form Id
- 71267770
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 5030376237383060006
- Ins Broker 01 Name
- SUMMIT GLOBAL PARTNERS OF FLORIDA
- Ins Broker 01 Street Addr
- 3651 FAU BOULEVARD
- Ins Broker 01 City
- BOCA RATON
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33431
- Ins Broker Comm Pd 01 Amount
- $4,156
- 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
- 84037237383566
- Form Id
- 71267766
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 5030376237383060002
- Ins Broker 01 Name
- SUMMIT GLOBAL PARTNERS OF FLORIDA
- Ins Broker 01 Street Addr
- 3651 FAU BOULEVARD
- Ins Broker 01 City
- BOCA RATON
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33431
- Ins Broker Comm Pd 01 Amount
- $2,704
- 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
- 84037237383566
- Form Id
- 71267767
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 5030376237383060003
- Ins Broker 01 Name
- SUMMIT GLOBAL PARTNERS OF FLORIDA
- Ins Broker 01 Street Addr
- 3651 FAU BOULEVARD
- Ins Broker 01 City
- BOCA RATON
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33431
- Ins Broker Comm Pd 01 Amount
- $38,369
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Text
- SALES AND SERVICE
- Ins Broker 01 Code
- 3
- Row 8
- Filing Id
- 84037237383566
- Form Id
- 71267769
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 5030376237383060005
- Ins Broker 01 Name
- SUMMIT GLOBAL PARTNERS OF FLORIDA
- Ins Broker 01 Street Addr
- 3651 FAU BOULEVARD
- Ins Broker 01 City
- BOCA RATON
- Ins Broker 01 State
- FL
- Ins Broker 01 ZIP Code
- 33431
- Ins Broker Comm Pd 01 Amount
- $949
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Text
- SALES AND SERVICE
- Ins Broker 01 Code
- 3
- Row 9
- Filing Id
- 84037237383566
- Form Id
- 71267772
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 2
- Row Num
- 1
- Image Form Id
- 5030376237383060008
- Ins Broker 01 Name
- STRATEGIC RESOURCE COMPANY
- Ins Broker 01 Street Addr
- 221 DAWSON ROAD
- Ins Broker 01 City
- COLUMBIA
- Ins Broker 01 State
- SC
- Ins Broker 01 ZIP Code
- 29223
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $4,102
- Ins Broker Fees Pd 01 Text
- ADMINISTRATIVE
- Ins Broker 01 Code
- 5
- Row 10
- Filing Id
- 84037237383566
- Form Id
- 71267773
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 2
- Row Num
- 1
- Image Form Id
- 5030376237383060009
- Ins Broker 01 Name
- STRATEGIC RESOURCE COMPANY
- Ins Broker 01 Street Addr
- 221 DAWSON ROAD
- Ins Broker 01 City
- COLUMBIA
- Ins Broker 01 State
- SC
- Ins Broker 01 ZIP Code
- 29223
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $446
- Ins Broker Fees Pd 01 Text
- ADMINISTRATIVE
- Ins Broker 01 Code
- 5
- Row 11
- Filing Id
- 84037237383566
- Form Id
- 71267771
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 2
- Row Num
- 1
- Image Form Id
- 5030376237383060007
- Ins Broker 01 Name
- STRATEGIC RESOURCE COMPANY
- Ins Broker 01 Street Addr
- 221 DAWSON ROAD
- Ins Broker 01 City
- COLUMBIA
- Ins Broker 01 State
- SC
- Ins Broker 01 ZIP Code
- 29223
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $63
- Ins Broker Fees Pd 01 Text
- ADMINISTRATIVE
- Ins Broker 01 Code
- 5
- Row 12
- Ins Carrier Name: JEFFERSON PILOT FINANCIAL INSURANCE COMPANY
- Filing Id
- 84037237383566
- Form Id
- 71267766
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2005-01-01
- Schedule A Tax Period
- 20051231
- Ins Carrier Name
- JEFFERSON PILOT FINANCIAL INSURANCE COMPANY
- Ins Carrier EIN
- 62-0395665
- Ins Carrier Naic Code
- 70254
- Ins Contract Num
- 000010064762
- Ins Prsn Covered End of year Count
- 295
- Ins Policy From Date
- 2004-11-01
- Ins Policy To Date
- 2005-10-31
- Ins Broker Comm Total Amount
- $2,704
- 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
- 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
- $18,030
- Wlfr Acquis Cost Amount
- $0
- Row 13
- Ins Carrier Name: EYEMED VISION CARE
- Filing Id
- 84037237383566
- Form Id
- 71267769
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2005-01-01
- Schedule A Tax Period
- 20051231
- Ins Carrier Name
- EYEMED VISION CARE
- Ins Carrier EIN
- 43-0949844
- Ins Carrier Naic Code
- 71870
- Ins Contract Num
- 9648452
- Ins Prsn Covered End of year Count
- 299
- Ins Policy From Date
- 2004-11-01
- Ins Policy To Date
- 2005-10-31
- Ins Broker Comm Total Amount
- $949
- 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
- $16,757
- Wlfr Acquis Cost Amount
- $0
- Row 14
- Ins Carrier Name: CONTINENTIAL CASUALTY COMPANY
- Filing Id
- 84037237383566
- Form Id
- 71267771
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2005-01-01
- Schedule A Tax Period
- 20051231
- Ins Carrier Name
- CONTINENTIAL CASUALTY COMPANY
- Ins Carrier EIN
- 36-2114545
- Ins Carrier Naic Code
- 20443
- Ins Contract Num
- CSA2130048800
- Ins Prsn Covered End of year Count
- 10
- Ins Policy From Date
- 2004-11-01
- Ins Policy To Date
- 2004-12-31
- Ins Broker Comm Total Amount
- $9
- Ins Broker Fees Total Amount
- $63
- 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
- $192
- Wlfr Acquis Cost Amount
- $0
- Row 15
- Ins Carrier Name: AETNA LIFE INSURANCE COMPANY
- Filing Id
- 84037237383566
- Form Id
- 71267773
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2005-01-01
- Schedule A Tax Period
- 20051231
- Ins Carrier Name
- AETNA LIFE INSURANCE COMPANY
- Ins Carrier EIN
- 06-6033492
- Ins Carrier Naic Code
- 60054
- Ins Contract Num
- ACN2100082201
- Ins Prsn Covered End of year Count
- 80
- Ins Policy From Date
- 2005-01-01
- Ins Policy To Date
- 2005-10-31
- Ins Broker Comm Total Amount
- $3,242
- Ins Broker Fees Total Amount
- $446
- 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
- ACDEL
- 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
- $64,840
- Wlfr Acquis Cost Amount
- $0
- Row 16
- Ins Carrier Name: COMPBENEFITS COMPANY
- Filing Id
- 84037237383566
- Form Id
- 71267770
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2005-01-01
- Schedule A Tax Period
- 20051231
- Ins Carrier Name
- COMPBENEFITS COMPANY
- Ins Carrier EIN
- 59-2531815
- Ins Carrier Naic Code
- 52015
- Ins Contract Num
- 57600
- Ins Prsn Covered End of year Count
- 330
- Ins Policy From Date
- 2004-11-01
- Ins Policy To Date
- 2005-10-31
- Ins Broker Comm Total Amount
- $4,156
- 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
- $43,978
- Wlfr Acquis Cost Amount
- $0
- Row 17
- Ins Carrier Name: HUMANA MEDICAL PLAN, INC
- Filing Id
- 84037237383566
- Form Id
- 71267767
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2005-01-01
- Schedule A Tax Period
- 20051231
- Ins Carrier Name
- HUMANA MEDICAL PLAN, INC
- Ins Carrier EIN
- 61-1103898
- Ins Carrier Naic Code
- 95270
- Ins Contract Num
- M5147
- Ins Prsn Covered End of year Count
- 211
- Ins Policy From Date
- 2004-11-01
- Ins Policy To Date
- 2005-10-31
- Ins Broker Comm Total Amount
- $38,369
- 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
- $775,176
- Wlfr Acquis Cost Amount
- $0
- Row 18
- Ins Carrier Name: CONTINENTIAL ASSURANCE COMPANY
- Filing Id
- 84037237383566
- Form Id
- 71267772
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2005-01-01
- Schedule A Tax Period
- 20051231
- Ins Carrier Name
- CONTINENTIAL ASSURANCE COMPANY
- Ins Carrier EIN
- 36-0947200
- Ins Carrier Naic Code
- 62413
- Ins Contract Num
- CMA2100082201
- Ins Prsn Covered End of year Count
- 114
- Ins Policy From Date
- 2004-11-01
- Ins Policy To Date
- 2004-12-31
- Ins Broker Comm Total Amount
- $786
- Ins Broker Fees Total Amount
- $4,102
- 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
- ACDL
- 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
- $15,725
- Wlfr Acquis Cost Amount
- $0
- Row 19
- Ins Carrier Name: HUMANA HEALTH INSURANCE COMPANY OF FLORIDA
- Filing Id
- 84037237383566
- Form Id
- 71267768
- Schedule A EIN
- 65-0420554
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2005-01-01
- Schedule A Tax Period
- 20051231
- Ins Carrier Name
- HUMANA HEALTH INSURANCE COMPANY OF FLORIDA
- Ins Carrier EIN
- 61-1041514
- Ins Carrier Naic Code
- 69671
- Ins Contract Num
- M5147
- Ins Prsn Covered End of year Count
- 9
- Ins Policy From Date
- 2004-11-01
- Ins Policy To Date
- 2005-10-31
- Ins Broker Comm Total Amount
- $6,659
- 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
- $133,194
- Wlfr Acquis Cost Amount
- $0