Schedule A
- Row 1
- Filing Id
- 84037086189042
- Form Id
- 13903033
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 10372086189040003
- Ins Broker 01 Name
- CMG CONSULTING, INC.
- Ins Broker 01 Street Addr
- 101 METRO DRIVE, SUITE 550
- Ins Broker 01 City
- SAN JOSE
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 95110
- Ins Broker Comm Pd 01 Amount
- $3,092
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 4
- Row 2
- Filing Id
- 84037086189042
- Form Id
- 13903032
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 10372086189040002
- Ins Broker 01 Name
- CMG CONSULTING, INC.
- Ins Broker 01 Street Addr
- 101 METRO DRIVE, SUITE 550
- Ins Broker 01 City
- SAN JOSE
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 95110
- Ins Broker Comm Pd 01 Amount
- $3,989
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 4
- Row 3
- Filing Id
- 84037086189042
- Form Id
- 13903034
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 10372086189040004
- Ins Broker 01 Name
- CMG CONSULTING, INC.
- Ins Broker 01 Street Addr
- 101 METRO DRIVE, SUITE 550
- Ins Broker 01 City
- SAN JOSE
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 95110
- Ins Broker Comm Pd 01 Amount
- $5,295
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 4
- Row 4
- Filing Id
- 84037086189042
- Form Id
- 13903036
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 10372086189040006
- Ins Broker 01 Name
- CMG CONSULTING, INC.
- Ins Broker 01 Street Addr
- 101 METRO DRIVE, SUITE 550
- Ins Broker 01 City
- SAN JOSE
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 95110
- Ins Broker Comm Pd 01 Amount
- $1,154
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 4
- Row 5
- Filing Id
- 84037086189042
- Form Id
- 13903037
- Page Id
- 1
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 10372086189040007
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $0
- Row 6
- Filing Id
- 84037086189042
- Form Id
- 13903035
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 10372086189040005
- Ins Broker 01 Name
- CMG CONSULTING, INC.
- Ins Broker 01 Street Addr
- 101 METRO DRIVE, SUITE 550
- Ins Broker 01 City
- SAN JOSE
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 95110
- Ins Broker Comm Pd 01 Amount
- $3,289
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 4
- Row 7
- Ins Carrier Name: KAISER PERMANENTE
- Filing Id
- 84037086189042
- Form Id
- 13903032
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2000-01-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- KAISER PERMANENTE
- Ins Carrier EIN
- 94-1340523
- Ins Contract Num
- 35536-0000
- Ins Prsn Covered End of year Count
- 39
- Ins Policy From Date
- 2000-01-01
- Ins Policy To Date
- 2000-12-31
- Ins Broker Comm Total Amount
- $3,989
- 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
- AJ
- 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
- $65,758
- Wlfr Acquis Cost Amount
- $0
- Row 8
- Ins Carrier Name: METLIFE
- Filing Id
- 84037086189042
- Form Id
- 13903033
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2000-01-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- METLIFE
- Ins Carrier EIN
- 13-5581829
- Ins Carrier Naic Code
- 65978
- Ins Contract Num
- 5536442
- Ins Prsn Covered End of year Count
- 132
- Ins Policy From Date
- 2000-01-01
- Ins Policy To Date
- 2000-12-31
- Ins Broker Comm Total Amount
- $3,092
- 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
- $81,810
- Wlfr Acquis Cost Amount
- $0
- Row 9
- Ins Carrier Name: RELIANCE STANDARD LIFE
- Filing Id
- 84037086189042
- Form Id
- 13903034
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2000-01-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- RELIANCE STANDARD LIFE
- Ins Carrier EIN
- 38-0883780
- Ins Carrier Naic Code
- 88381
- Ins Contract Num
- GL027448
- Ins Prsn Covered End of year Count
- 138
- Ins Policy From Date
- 2000-01-01
- Ins Policy To Date
- 2000-12-31
- Ins Broker Comm Total Amount
- $5,295
- 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
- D
- 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
- $44,122
- Wlfr Acquis Cost Amount
- $0
- Row 10
- Ins Carrier Name: RELIANCE STANDARD LIFE
- Filing Id
- 84037086189042
- Form Id
- 13903035
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2000-01-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- RELIANCE STANDARD LIFE
- Ins Carrier EIN
- 38-0883780
- Ins Carrier Naic Code
- 88381
- Ins Contract Num
- LTD098345
- Ins Prsn Covered End of year Count
- 138
- Ins Policy From Date
- 2000-01-01
- Ins Policy To Date
- 2000-12-31
- Ins Broker Comm Total Amount
- $3,289
- Ins Broker Fees Total Amount
- $0
- Pension End of year Gen Account Amount
- $0
- Pension End of year Sep Account Amount
- $1
- 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
- $26,805
- Wlfr Acquis Cost Amount
- $0
- Row 11
- Ins Carrier Name: VISION SERVICE PLAN
- Filing Id
- 84037086189042
- Form Id
- 13903036
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2000-01-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- VISION SERVICE PLAN
- Ins Carrier EIN
- 94-1632821
- Ins Contract Num
- 12017034
- Ins Prsn Covered End of year Count
- 129
- Ins Policy From Date
- 2000-01-01
- Ins Policy To Date
- 2000-12-31
- Ins Broker Comm Total Amount
- $1,154
- 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
- $21,858
- Wlfr Acquis Cost Amount
- $0
- Row 12
- Ins Carrier Name: GREAT WEST LIFE & ANNUITY INSURANCE COMPANY
- Filing Id
- 84037086189042
- Form Id
- 13903037
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2000-01-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- GREAT WEST LIFE & ANNUITY INSURANCE COMPANY
- Ins Carrier EIN
- 94-0487307
- Ins Carrier Naic Code
- 58322
- Ins Contract Num
- 269942
- Ins Prsn Covered End of year Count
- 130
- Ins Policy From Date
- 2000-01-01
- Ins Policy To Date
- 2000-12-31
- 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
- AD&D
- 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
- $8,035
- Wlfr Acquis Cost Amount
- $0