Schedule A
- Row 1
- Filing Id
- 56037128185521
- Form Id
- 4550399
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 30371128185020004
- Ins Broker 01 Name
- HOVER INSURANCE SERVICES
- Ins Broker 01 Street Addr
- 415 A STREET
- Ins Broker 01 City
- PETALUMA
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94952
- Ins Broker Comm Pd 01 Amount
- $35,260
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 2
- Filing Id
- 56037128185521
- Form Id
- 4550400
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 30371128185020005
- Ins Broker 01 Name
- DAVID W. HOVER
- Ins Broker 01 Street Addr
- 415 A STREET
- Ins Broker 01 City
- PETALUMA
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94952
- Ins Broker Comm Pd 01 Amount
- $14,518
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 3
- Filing Id
- 56037128185521
- Form Id
- 4550398
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 3
- Row Num
- 0
- Image Form Id
- 30371128185020003
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $0
- Row 4
- Filing Id
- 56037128185521
- Form Id
- 4550396
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 30371128185020002
- Ins Broker 01 Name
- DAVID W. HOVER
- Ins Broker 01 Street Addr
- HOVER INSURANCE SERVICES
- Ins Broker 01 City
- 415 A STREET PETALUMA
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94952
- Ins Broker Comm Pd 01 Amount
- $1,977
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 5
- Filing Id
- 56037128185521
- Form Id
- 4550400
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 2
- Row Num
- 1
- Image Form Id
- 30371128185020005
- Ins Broker 01 Name
- HOVER INSURANCE SERVICES
- Ins Broker 01 Street Addr
- 415 A STREET
- Ins Broker 01 City
- PETALUMA
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94952
- Ins Broker Comm Pd 01 Amount
- $892
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 6
- Ins Carrier Name: UNITED HEALTHCARE
- Filing Id
- 56037128185521
- Form Id
- 4550399
- Schedule A EIN
- 77-0241520
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 1999-01-01
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- UNITED HEALTHCARE
- Ins Carrier Naic Code
- 000
- Ins Contract Num
- 176746
- Ins Prsn Covered End of year Count
- 236
- Ins Policy From Date
- 1999-01-01
- Ins Policy To Date
- 1999-12-31
- Ins Broker Comm Total Amount
- $35,260
- 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
- $1,170,130
- Wlfr Acquis Cost Amount
- $0
- Row 7
- Ins Carrier Name: PRINCIPAL FINANCIAL GROUP
- Filing Id
- 56037128185521
- Form Id
- 4550400
- Schedule A EIN
- 77-0241520
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 1999-01-01
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- PRINCIPAL FINANCIAL GROUP
- Ins Carrier Naic Code
- 3328
- Ins Contract Num
- N93435
- Ins Prsn Covered End of year Count
- 398
- Ins Policy From Date
- 1999-01-01
- Ins Policy To Date
- 1999-12-31
- Ins Broker Comm Total Amount
- $15,410
- 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
- BF
- 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
- $334,594
- Wlfr Acquis Cost Amount
- $0
- Row 8
- Ins Carrier Name: METROPOLITAN LIFE
- Filing Id
- 56037128185521
- Form Id
- 4550398
- Schedule A EIN
- 77-0241520
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 1999-01-01
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- METROPOLITAN LIFE
- Ins Carrier EIN
- 13-5581829
- Ins Carrier Naic Code
- 65978
- Ins Contract Num
- 6074722
- Ins Prsn Covered End of year Count
- 210
- Ins Policy From Date
- 1999-01-01
- Ins Policy To Date
- 1999-12-31
- 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
- DM
- Wlfr Type Bnft Oth Text
- ACCIDENTAL DEATH & 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
- $54,170
- Wlfr Acquis Cost Amount
- $0
- Row 9
- Filing Id
- 56037128185521
- Form Id
- 4550396
- Schedule A EIN
- 77-0241520
- Schedule A Plan Year Begin Date
- 1999-01-01
- Schedule A Tax Period
- 19991231
- 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
- $57,568
- Wlfr Acquis Cost Amount
- $0