Schedule A
- Row 1
- Filing Id
- 84037085127553
- Form Id
- 28780368
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 1030373085127050004
- Ins Broker 01 Name
- CALCO INSURANCE BROKERS & AGENTS
- Ins Broker 01 Street Addr
- 2000 ALAMEDA DE LAS PULGAS
- Ins Broker 01 City
- SAN MATEO
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94403
- Ins Broker Comm Pd 01 Amount
- $6,393
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 2
- Filing Id
- 84037085127553
- Form Id
- 28780366
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 1030373085127050002
- Ins Broker 01 Name
- CALCO INSURANCE BROKERS & AGENTS
- Ins Broker 01 Street Addr
- 2000 ALAMEDA DE LAS PULGAS
- Ins Broker 01 City
- SAN MATEO
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94403
- Ins Broker Comm Pd 01 Amount
- $7,340
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 3
- Filing Id
- 84037085127553
- Form Id
- 28780367
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 1030373085127050003
- Ins Broker 01 Name
- CALCO INSURANCE BROKERS & AGENTS
- Ins Broker 01 Street Addr
- P.O. BOX M
- Ins Broker 01 City
- SAN MATEO
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94402
- Ins Broker Comm Pd 01 Amount
- $22,577
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 4
- Filing Id
- 84037085127553
- Form Id
- 28780369
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 1030373085127050005
- Ins Broker 01 Name
- CALCO INSURANCE BROKERS & AGENTS
- Ins Broker 01 Street Addr
- 2000 ALAMEDA DE LAS PULGAS
- Ins Broker 01 City
- SAN MATEO
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94403
- Ins Broker Comm Pd 01 Amount
- $1,766
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 5
- Filing Id
- 84037085127553
- Form Id
- 28780370
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 1030373085127050006
- Ins Broker 01 Name
- CALCO INSURANCE BROKERS & AGENTS
- Ins Broker 01 Street Addr
- 2000 ALAMEDA DE LAS PULGAS
- Ins Broker 01 City
- SAN MATEO
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94403
- Ins Broker Comm Pd 01 Amount
- $80
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 6
- Ins Carrier Name: HIGHMARK LIFE INSURANCE COMPANY
- Filing Id
- 84037085127553
- Form Id
- 28780366
- Schedule A EIN
- 77-0336723
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2001-04-01
- Schedule A Tax Period
- 20020331
- Ins Carrier Name
- HIGHMARK LIFE INSURANCE COMPANY
- Ins Carrier EIN
- 06-1041332
- Ins Carrier Naic Code
- 93440
- Ins Contract Num
- 911414
- Ins Prsn Covered End of year Count
- 72
- Ins Policy From Date
- 2001-04-01
- Ins Policy To Date
- 2002-03-31
- Ins Broker Comm Total Amount
- $7,340
- 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
- DEF
- 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
- $65,113
- Wlfr Acquis Cost Amount
- $0
- Row 7
- Ins Carrier Name: BLUE CROSS OF CALIFORNIA
- Filing Id
- 84037085127553
- Form Id
- 28780367
- Schedule A EIN
- 77-0336723
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2001-04-01
- Schedule A Tax Period
- 20020331
- Ins Carrier Name
- BLUE CROSS OF CALIFORNIA
- Ins Carrier EIN
- 95-3760980
- Ins Carrier Naic Code
- 00000
- Ins Contract Num
- C23098
- Ins Prsn Covered End of year Count
- 72
- Ins Policy From Date
- 2001-04-01
- Ins Policy To Date
- 2002-03-31
- Ins Broker Comm Total Amount
- $22,577
- 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
- $451,533
- Wlfr Acquis Cost Amount
- $0
- Row 8
- Ins Carrier Name: DELTA DENTAL PLAN OF CALIFORNIA
- Filing Id
- 84037085127553
- Form Id
- 28780368
- Schedule A EIN
- 77-0336723
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2001-04-01
- Schedule A Tax Period
- 20020331
- Ins Carrier Name
- DELTA DENTAL PLAN OF CALIFORNIA
- Ins Carrier EIN
- 94-1461312
- Ins Carrier Naic Code
- 00000
- Ins Contract Num
- 8274-0005
- Ins Prsn Covered End of year Count
- 79
- Ins Policy From Date
- 2001-04-01
- Ins Policy To Date
- 2002-03-31
- Ins Broker Comm Total Amount
- $6,393
- 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
- $106,552
- Wlfr Acquis Cost Amount
- $0
- Row 9
- Ins Carrier Name: VISION SERVICE PLAN
- Filing Id
- 84037085127553
- Form Id
- 28780369
- Schedule A EIN
- 77-0336723
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2001-04-01
- Schedule A Tax Period
- 20020331
- Ins Carrier Name
- VISION SERVICE PLAN
- Ins Carrier EIN
- 94-1632821
- Ins Carrier Naic Code
- 00000
- Ins Contract Num
- 12114411
- Ins Prsn Covered End of year Count
- 74
- Ins Policy From Date
- 2001-01-01
- Ins Policy To Date
- 2001-12-31
- Ins Broker Comm Total Amount
- $1,766
- 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
- $17,656
- Wlfr Acquis Cost Amount
- $0
- Row 10
- Ins Carrier Name: HOLMAN FAMILY COUNSELING CENTERS
- Filing Id
- 84037085127553
- Form Id
- 28780370
- Schedule A EIN
- 77-0336723
- Schedule A Plan Num
- 502
- Schedule A Plan Year Begin Date
- 2001-04-01
- Schedule A Tax Period
- 20020331
- Ins Carrier Name
- HOLMAN FAMILY COUNSELING CENTERS
- Ins Carrier EIN
- 95-3966486
- Ins Carrier Naic Code
- 00000
- Ins Contract Num
- 1632
- Ins Prsn Covered End of year Count
- 70
- Ins Policy From Date
- 2001-01-01
- Ins Policy To Date
- 2001-12-31
- Ins Broker Comm Total Amount
- $80
- 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
- EMPLOYEE ASSISTANCE PROGRAM
- 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
- $1,713
- Wlfr Acquis Cost Amount
- $0