Schedule A
- Row 1
- Filing Id
- 84037222053304
- Form Id
- 49500588
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3020374222053050007
- Ins Broker 01 Name
- SAYLOR & HILL CO.
- Ins Broker 01 Street Addr
- 1939 HARRISON ST., SUITE 900
- Ins Broker 01 City
- OAKLAND
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94612
- Ins Broker Comm Pd 01 Amount
- $525
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 2
- Filing Id
- 84037222053304
- Form Id
- 49500583
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3020374222053050002
- Ins Broker 01 Name
- SAYLOR & HILL CO.
- Ins Broker 01 Street Addr
- 1939 HARRISON ST., SUITE 900
- Ins Broker 01 City
- OAKLAND
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94612
- Ins Broker Comm Pd 01 Amount
- $32,049
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 3
- Filing Id
- 84037222053304
- Form Id
- 49500584
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3020374222053050003
- Ins Broker 01 Name
- SAYLOR & HILL CO.
- Ins Broker 01 Street Addr
- 1939 HARRISON ST., SUITE 900
- Ins Broker 01 City
- OAKLAND
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94612
- Ins Broker Comm Pd 01 Amount
- $4,533
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 4
- Filing Id
- 84037222053304
- Form Id
- 49500585
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3020374222053050004
- Ins Broker 01 Name
- SAYLOR & HILL CO.
- Ins Broker 01 Street Addr
- 1939 HARRISON ST., 900
- Ins Broker 01 City
- OAKLAND
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94612
- Ins Broker Comm Pd 01 Amount
- $7,931
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 5
- Filing Id
- 84037222053304
- Form Id
- 49500586
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3020374222053050005
- Ins Broker 01 Name
- SAYLOR & HILL CO.
- Ins Broker 01 Street Addr
- 1939 HARRISON ST., 900
- Ins Broker 01 City
- OAKLAND
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94612
- Ins Broker Comm Pd 01 Amount
- $8,587
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 6
- Filing Id
- 84037222053304
- Form Id
- 49500587
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 3020374222053050006
- Ins Broker 01 Name
- SAYLOR & HILL CO.
- Ins Broker 01 Street Addr
- 1939 HARRISON ST., SUITE 900
- Ins Broker 01 City
- OAKLAND
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94612
- Ins Broker Comm Pd 01 Amount
- $1,328
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 7
- Ins Carrier Name: BLUE CROSS
- Filing Id
- 84037222053304
- Form Id
- 49500583
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- BLUE CROSS
- Ins Carrier EIN
- 95-3760980
- Ins Carrier Naic Code
- 0
- Ins Contract Num
- 150871
- Ins Prsn Covered End of year Count
- 99
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- Ins Broker Comm Total Amount
- $32,049
- 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
- ADJKM
- 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
- $634,972
- Wlfr Acquis Cost Amount
- $0
- Row 8
- Ins Carrier Name: KAISER
- Filing Id
- 84037222053304
- Form Id
- 49500584
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- KAISER
- Ins Carrier EIN
- 94-1340523
- Ins Carrier Naic Code
- 0
- Ins Contract Num
- 35536-0000
- Ins Prsn Covered End of year Count
- 18
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- Ins Broker Comm Total Amount
- $4,533
- 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
- HJ
- 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
- $54,756
- Wlfr Acquis Cost Amount
- $0
- Row 9
- Ins Carrier Name: DELTA DENTAL
- Filing Id
- 84037222053304
- Form Id
- 49500585
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- DELTA DENTAL
- Ins Carrier EIN
- 94-1461312
- Ins Carrier Naic Code
- 0
- Ins Contract Num
- 2381
- Ins Prsn Covered End of year Count
- 86
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- Ins Broker Comm Total Amount
- $7,931
- 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
- $158,614
- Wlfr Acquis Cost Amount
- $0
- Row 10
- Ins Carrier Name: RELIANCE STANDARD
- Filing Id
- 84037222053304
- Form Id
- 49500586
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- RELIANCE STANDARD
- Ins Carrier EIN
- 36-0883760
- Ins Carrier Naic Code
- 88381
- Ins Contract Num
- GL027446
- Ins Prsn Covered End of year Count
- 70
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- Ins Broker Comm Total Amount
- $8,587
- 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
- DFM
- 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
- $74,784
- Wlfr Acquis Cost Amount
- $0
- Row 11
- Ins Carrier Name: VISION SERVICE PLAN
- Filing Id
- 84037222053304
- Form Id
- 49500587
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- VISION SERVICE PLAN
- Ins Carrier EIN
- 94-1632821
- Ins Carrier Naic Code
- 0
- Ins Contract Num
- 12017034
- Ins Prsn Covered End of year Count
- 137
- Ins Policy From Date
- 2003-01-01
- Ins Policy To Date
- 2003-12-31
- Ins Broker Comm Total Amount
- $1,328
- 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
- $27,907
- Wlfr Acquis Cost Amount
- $0
- Row 12
- Ins Carrier Name: AIG
- Filing Id
- 84037222053304
- Form Id
- 49500588
- Schedule A EIN
- 77-0311961
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2003-01-01
- Schedule A Tax Period
- 20031231
- Ins Carrier Name
- AIG
- Ins Carrier EIN
- 25-1118523
- Ins Carrier Naic Code
- 66842
- Ins Contract Num
- GLB9026255
- Ins Prsn Covered End of year Count
- 87
- Ins Policy From Date
- 2002-04-08
- Ins Policy To Date
- 2003-04-08
- Ins Broker Comm Total Amount
- $525
- 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
- M
- Wlfr Type Bnft Oth Text
- TRAVEL ACCIDENT
- 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
- $3,500
- Wlfr Acquis Cost Amount
- $0