Civic Intelligence
Filing

Tibco Software Health & Welfare Plan

Tibco Software Inc. • EIN 77-0449727 • Plan year 2003

Company ProfileSource Archive
Filing Insights

Participants

Down

853 → 725

-128 • -15.01%

Assets

No comparison

- → -

No earlier value available.

Investment Management Fee

-

Admin expenses - • Total expenses -

Filing Details

Context

No event flags were generated for this filing.

Status Flags

Fidelity bond in place

Not reported

Limited-scope audit performed

Not reported

Contributions transmitted on time

Not reported

Participant loans in default

Not reported

Leases in default

Not reported

Reportable party-in-interest issues

Not reported

Loss discovered during year

Not reported

Assets with undetermined value

Not reported

Non-cash contributions

Not reported

Assets held for investment

Not reported

5% transactions reported

Not reported

All plan assets distributed

Not reported

Benefits paid when due

Not reported

Plan blackout period

Not reported

Plan termination resolution adopted

Not reported

Counterparties

Company Timeline

This filing is highlighted inside the broader sponsor history.

Year / FilingFilingsParticipantsAssetsContributionsContrib./Participant
202442,051$1,604,843,511$86,073,172$41,966iApproximate average salary by contribution assumption: employee only about $1,049,161 at 4% or $699,441 at 6%; with 50% employer match about $699,441 at 4% or $466,294 at 6%; with 100% employer match about $524,581 at 4% or $349,720 at 6%.
Tibco Software Inc. 401K Savings Plan-2,051$1,604,843,511$53,241,889$25,959iApproximate average salary by contribution assumption: employee only about $648,975 at 4% or $432,650 at 6%; with 50% employer match about $432,650 at 4% or $288,433 at 6%; with 100% employer match about $324,487 at 4% or $216,325 at 6%.
Cloud Software Group Inc Welfare Benefits Plan-2,045---
Cloud Software Group Inc. Severaance Pay Paln-1,946---
Tibco Software Inc. 401(K) Savings Plan-0-$32,831,283-
202333,226$959,866,290$60,018,237$18,605iApproximate average salary by contribution assumption: employee only about $465,113 at 4% or $310,076 at 6%; with 50% employer match about $310,076 at 4% or $206,717 at 6%; with 100% employer match about $232,557 at 4% or $155,038 at 6%.
Tibco Software Inc. 401K Savings Plan-1,953$959,866,290$60,018,237$30,731iApproximate average salary by contribution assumption: employee only about $768,283 at 4% or $512,188 at 6%; with 50% employer match about $512,188 at 4% or $341,459 at 6%; with 100% employer match about $384,141 at 4% or $256,094 at 6%.
Cloud Software Group Inc Welfare Benefits Plan-3,226---
Cloud Software Group Inc. Severaance Pay Paln-2,999---
202232,923$827,464,216$67,085,253$22,951iApproximate average salary by contribution assumption: employee only about $573,771 at 4% or $382,514 at 6%; with 50% employer match about $382,514 at 4% or $255,009 at 6%; with 100% employer match about $286,885 at 4% or $191,257 at 6%.
Tibco Software Inc. 401K Savings Plan-2,821$827,464,216$67,085,253$23,781iApproximate average salary by contribution assumption: employee only about $594,517 at 4% or $396,344 at 6%; with 50% employer match about $396,344 at 4% or $264,230 at 6%; with 100% employer match about $297,258 at 4% or $198,172 at 6%.
Cloud Software Group Inc Welfare Benefits Plan-2,923---
Tibco Software Health & Welfare Plan-0---
202121,496$575,842,132$131,524,764$87,918iApproximate average salary by contribution assumption: employee only about $2,197,941 at 4% or $1,465,294 at 6%; with 50% employer match about $1,465,294 at 4% or $976,862 at 6%; with 100% employer match about $1,098,970 at 4% or $732,647 at 6%.
Tibco Software Inc. 401K Savings Plan-1,496$575,842,132$131,524,764$87,918iApproximate average salary by contribution assumption: employee only about $2,197,941 at 4% or $1,465,294 at 6%; with 50% employer match about $1,465,294 at 4% or $976,862 at 6%; with 100% employer match about $1,098,970 at 4% or $732,647 at 6%.
Tibco Software Health & Welfare Plan-1,376---
202021,199$417,236,971$30,757,507$25,653iApproximate average salary by contribution assumption: employee only about $641,316 at 4% or $427,544 at 6%; with 50% employer match about $427,544 at 4% or $285,029 at 6%; with 100% employer match about $320,658 at 4% or $213,772 at 6%.
Tibco Software Inc. 401K Savings Plan-1,199$417,236,971$30,757,507$25,653iApproximate average salary by contribution assumption: employee only about $641,316 at 4% or $427,544 at 6%; with 50% employer match about $427,544 at 4% or $285,029 at 6%; with 100% employer match about $320,658 at 4% or $213,772 at 6%.
Tibco Software Health & Welfare Plan-1,039---
201921,419$387,424,065$32,287,986$22,754iApproximate average salary by contribution assumption: employee only about $568,851 at 4% or $379,234 at 6%; with 50% employer match about $379,234 at 4% or $252,823 at 6%; with 100% employer match about $284,426 at 4% or $189,617 at 6%.
Tibco Software Inc. 401K Savings Plan-1,419$387,424,065$32,287,986$22,754iApproximate average salary by contribution assumption: employee only about $568,851 at 4% or $379,234 at 6%; with 50% employer match about $379,234 at 4% or $252,823 at 6%; with 100% employer match about $284,426 at 4% or $189,617 at 6%.
Tibco Software Health & Welfare Plan-1,409---
201821,547$316,445,693$31,998,124$20,684iApproximate average salary by contribution assumption: employee only about $517,100 at 4% or $344,733 at 6%; with 50% employer match about $344,733 at 4% or $229,822 at 6%; with 100% employer match about $258,550 at 4% or $172,367 at 6%.
Tibco Software Inc. 401K Savings Plan-1,547$316,445,693$31,998,124$20,684iApproximate average salary by contribution assumption: employee only about $517,100 at 4% or $344,733 at 6%; with 50% employer match about $344,733 at 4% or $229,822 at 6%; with 100% employer match about $258,550 at 4% or $172,367 at 6%.
Tibco Software Health & Welfare Plan-1,479---
201721,489$328,029,746$27,937,221$18,762iApproximate average salary by contribution assumption: employee only about $469,060 at 4% or $312,707 at 6%; with 50% employer match about $312,707 at 4% or $208,471 at 6%; with 100% employer match about $234,530 at 4% or $156,353 at 6%.
Tibco Software Inc. 401K Savings Plan-1,410$328,029,746$27,937,221$19,814iApproximate average salary by contribution assumption: employee only about $495,341 at 4% or $330,227 at 6%; with 50% employer match about $330,227 at 4% or $220,151 at 6%; with 100% employer match about $247,670 at 4% or $165,114 at 6%.
Tibco Software Health & Welfare Plan-1,489---
201621,375$279,287,393$25,790,804$18,757iApproximate average salary by contribution assumption: employee only about $468,924 at 4% or $312,616 at 6%; with 50% employer match about $312,616 at 4% or $208,411 at 6%; with 100% employer match about $234,462 at 4% or $156,308 at 6%.
Tibco Software Inc. 401K Savings Plan-1,374$279,287,393$25,790,804$18,771iApproximate average salary by contribution assumption: employee only about $469,265 at 4% or $312,843 at 6%; with 50% employer match about $312,843 at 4% or $208,562 at 6%; with 100% employer match about $234,632 at 4% or $156,422 at 6%.
Tibco Software Health & Welfare Plan-1,375---
201521,550$258,108,519$28,599,352$18,451iApproximate average salary by contribution assumption: employee only about $461,280 at 4% or $307,520 at 6%; with 50% employer match about $307,520 at 4% or $205,013 at 6%; with 100% employer match about $230,640 at 4% or $153,760 at 6%.
Tibco Software Inc. 401K Savings Plan-1,314$258,108,519$28,599,352$21,765iApproximate average salary by contribution assumption: employee only about $544,128 at 4% or $362,752 at 6%; with 50% employer match about $362,752 at 4% or $241,835 at 6%; with 100% employer match about $272,064 at 4% or $181,376 at 6%.
Tibco Software Health & Welfare Plan-1,550---
201421,929$267,589,805$31,235,266$16,192iApproximate average salary by contribution assumption: employee only about $404,812 at 4% or $269,874 at 6%; with 50% employer match about $269,874 at 4% or $179,916 at 6%; with 100% employer match about $202,406 at 4% or $134,937 at 6%.
Tibco Software Inc. 401K Savings Plan-1,827$267,589,805$31,235,266$17,096iApproximate average salary by contribution assumption: employee only about $427,412 at 4% or $284,941 at 6%; with 50% employer match about $284,941 at 4% or $189,961 at 6%; with 100% employer match about $213,706 at 4% or $142,471 at 6%.
Tibco Software Health & Welfare Plan-1,929---
201321,764$238,765,261$29,378,410$16,654iApproximate average salary by contribution assumption: employee only about $416,361 at 4% or $277,574 at 6%; with 50% employer match about $277,574 at 4% or $185,049 at 6%; with 100% employer match about $208,180 at 4% or $138,787 at 6%.
Tibco Software Inc. 401K Savings Plan-1,757$238,765,261$29,378,410$16,721iApproximate average salary by contribution assumption: employee only about $418,019 at 4% or $278,680 at 6%; with 50% employer match about $278,680 at 4% or $185,786 at 6%; with 100% employer match about $209,010 at 4% or $139,340 at 6%.
Tibco Software Health & Welfare Plan-1,764---
201221,738$185,189,612$26,815,343$15,429iApproximate average salary by contribution assumption: employee only about $385,721 at 4% or $257,148 at 6%; with 50% employer match about $257,148 at 4% or $171,432 at 6%; with 100% employer match about $192,861 at 4% or $128,574 at 6%.
Tibco Software Inc. 401K Savings Plan-1,704$185,189,612$26,815,343$15,737iApproximate average salary by contribution assumption: employee only about $393,418 at 4% or $262,278 at 6%; with 50% employer match about $262,278 at 4% or $174,852 at 6%; with 100% employer match about $196,709 at 4% or $131,139 at 6%.
Tibco Software Health & Welfare Plan-1,738---
201121,487$149,668,753$23,643,437$15,900iApproximate average salary by contribution assumption: employee only about $397,502 at 4% or $265,002 at 6%; with 50% employer match about $265,002 at 4% or $176,668 at 6%; with 100% employer match about $198,751 at 4% or $132,501 at 6%.
Tibco Software Inc. 401K Savings Plan-1,474$149,668,753$23,643,437$16,040iApproximate average salary by contribution assumption: employee only about $401,008 at 4% or $267,339 at 6%; with 50% employer match about $267,339 at 4% or $178,226 at 6%; with 100% employer match about $200,504 at 4% or $133,669 at 6%.
Tibco Software Health & Welfare Plan-1,487---
201021,406$133,551,543$20,673,982$14,704iApproximate average salary by contribution assumption: employee only about $367,603 at 4% or $245,069 at 6%; with 50% employer match about $245,069 at 4% or $163,379 at 6%; with 100% employer match about $183,801 at 4% or $122,534 at 6%.
Tibco Software Inc. 401K Savings Plan-1,226$133,551,543$20,673,982$16,863iApproximate average salary by contribution assumption: employee only about $421,574 at 4% or $281,049 at 6%; with 50% employer match about $281,049 at 4% or $187,366 at 6%; with 100% employer match about $210,787 at 4% or $140,525 at 6%.
Tibco Software Health & Welfare Plan-1,406---
200921,425$104,382,381$15,963,709$11,203iApproximate average salary by contribution assumption: employee only about $280,065 at 4% or $186,710 at 6%; with 50% employer match about $186,710 at 4% or $124,473 at 6%; with 100% employer match about $140,033 at 4% or $93,355 at 6%.
Tibco Software Inc. 401K Savings Plan-1,026$104,382,381$15,963,709$15,559iApproximate average salary by contribution assumption: employee only about $388,979 at 4% or $259,320 at 6%; with 50% employer match about $259,320 at 4% or $172,880 at 6%; with 100% employer match about $194,490 at 4% or $129,660 at 6%.
Tibco Software Health & Welfare Plan-1,425---
200821,420$74,399,354$16,941,727$11,931iApproximate average salary by contribution assumption: employee only about $298,270 at 4% or $198,847 at 6%; with 50% employer match about $198,847 at 4% or $132,564 at 6%; with 100% employer match about $149,135 at 4% or $99,423 at 6%.
Tibco Software Inc. 401K Savings Plan-1,026$74,399,354$16,941,727$16,512iApproximate average salary by contribution assumption: employee only about $412,810 at 4% or $275,207 at 6%; with 50% employer match about $275,207 at 4% or $183,471 at 6%; with 100% employer match about $206,405 at 4% or $137,603 at 6%.
Tibco Software Health & Welfare Plan-1,420---
200721,018$80,374,182$14,011,341$13,764iApproximate average salary by contribution assumption: employee only about $344,090 at 4% or $229,393 at 6%; with 50% employer match about $229,393 at 4% or $152,929 at 6%; with 100% employer match about $172,045 at 4% or $114,697 at 6%.
Tibco Software Inc. 401K Savings Plan-952$80,374,182$14,011,341$14,718iApproximate average salary by contribution assumption: employee only about $367,945 at 4% or $245,297 at 6%; with 50% employer match about $245,297 at 4% or $163,531 at 6%; with 100% employer match about $183,972 at 4% or $122,648 at 6%.
Tibco Software Health & Welfare Plan-1,018---
20062898$80,374,182$14,011,341$15,603iApproximate average salary by contribution assumption: employee only about $390,071 at 4% or $260,047 at 6%; with 50% employer match about $260,047 at 4% or $173,365 at 6%; with 100% employer match about $195,035 at 4% or $130,024 at 6%.
Tibco Software Inc. 401K Savings Plan-832$80,374,182$14,011,341$16,841iApproximate average salary by contribution assumption: employee only about $421,014 at 4% or $280,676 at 6%; with 50% employer match about $280,676 at 4% or $187,117 at 6%; with 100% employer match about $210,507 at 4% or $140,338 at 6%.
Tibco Software Health & Welfare Plan-898---
20052850$63,883,249$12,417,707$14,609iApproximate average salary by contribution assumption: employee only about $365,227 at 4% or $243,484 at 6%; with 50% employer match about $243,484 at 4% or $162,323 at 6%; with 100% employer match about $182,613 at 4% or $121,742 at 6%.
Tibco Software Inc. 401K Savings Plan-778$63,883,249$12,417,707$15,961iApproximate average salary by contribution assumption: employee only about $399,027 at 4% or $266,018 at 6%; with 50% employer match about $266,018 at 4% or $177,345 at 6%; with 100% employer match about $199,513 at 4% or $133,009 at 6%.
Tibco Software Health & Welfare Plan-850---
20042837$48,577,644$9,402,030$11,233iApproximate average salary by contribution assumption: employee only about $280,825 at 4% or $187,217 at 6%; with 50% employer match about $187,217 at 4% or $124,811 at 6%; with 100% employer match about $140,413 at 4% or $93,608 at 6%.
Tibco Software Inc. 401K Savings Plan-669$48,577,644$9,402,030$14,054iApproximate average salary by contribution assumption: employee only about $351,346 at 4% or $234,231 at 6%; with 50% employer match about $234,231 at 4% or $156,154 at 6%; with 100% employer match about $175,673 at 4% or $117,115 at 6%.
Tibco Software Health & Welfare Plan-837---
20032725$37,804,062$9,222,897$12,721iApproximate average salary by contribution assumption: employee only about $318,031 at 4% or $212,021 at 6%; with 50% employer match about $212,021 at 4% or $141,347 at 6%; with 100% employer match about $159,015 at 4% or $106,010 at 6%.
Tibco Software Inc. 401K Savings Plan-632$37,804,062$9,222,897$14,593iApproximate average salary by contribution assumption: employee only about $364,830 at 4% or $243,220 at 6%; with 50% employer match about $243,220 at 4% or $162,147 at 6%; with 100% employer match about $182,415 at 4% or $121,610 at 6%.
Tibco Software Health & Welfare PlanCurrent725---
20022853$24,657,789$9,412,062$11,034iApproximate average salary by contribution assumption: employee only about $275,852 at 4% or $183,901 at 6%; with 50% employer match about $183,901 at 4% or $122,601 at 6%; with 100% employer match about $137,926 at 4% or $91,951 at 6%.
Tibco Software Inc. 401K Savings Plan-741$24,657,789$9,412,062$12,702iApproximate average salary by contribution assumption: employee only about $317,546 at 4% or $211,697 at 6%; with 50% employer match about $211,697 at 4% or $141,132 at 6%; with 100% employer match about $158,773 at 4% or $105,849 at 6%.
Tibco Software Health & Welfare Plan-853---
20012853$0$0-
Tibco Software Health & Welfare Plan-853---
Tibco Software Inc. 401K Savings Plan-741---
20002808$19,216,107$5,500,550$6,808iApproximate average salary by contribution assumption: employee only about $170,190 at 4% or $113,460 at 6%; with 50% employer match about $113,460 at 4% or $75,640 at 6%; with 100% employer match about $85,095 at 4% or $56,730 at 6%.
Tibco Software Inc. 401K Savings Plan-574$19,216,107$5,500,550$9,583iApproximate average salary by contribution assumption: employee only about $239,571 at 4% or $159,714 at 6%; with 50% employer match about $159,714 at 4% or $106,476 at 6%; with 100% employer match about $119,785 at 4% or $79,857 at 6%.
Tibco Software Health & Welfare Plan-808---
19992459$16,378,687$1,292,162$2,815iApproximate average salary by contribution assumption: employee only about $70,379 at 4% or $46,919 at 6%; with 50% employer match about $46,919 at 4% or $31,280 at 6%; with 100% employer match about $35,190 at 4% or $23,460 at 6%.
Tibco Software Inc. 401K Savings Plan-327$16,378,687$1,292,162$3,952iApproximate average salary by contribution assumption: employee only about $98,789 at 4% or $65,859 at 6%; with 50% employer match about $65,859 at 4% or $43,906 at 6%; with 100% employer match about $49,395 at 4% or $32,930 at 6%.
Tibco Software Health & Welfare Plan-459---
Schedule Details

Schedule A

Row 1
Filing Id
91037023239036
Form Id
66773554
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
3030374300448050004
Ins Broker 01 Name
ABD INSURANCE & FINANCIAL SERVICES
Ins Broker 01 Street Addr
305 WALNUT STREET
Ins Broker 01 City
REDWOOD CITY
Ins Broker 01 State
CA
Ins Broker 01 ZIP Code
94063
Ins Broker Comm Pd 01 Amount
$18,626
Ins Broker Fees Pd 01 Amount
$0
Ins Broker 01 Code
3
Row 2
Filing Id
91037023239036
Form Id
66773551
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
3030374300448050002
Ins Broker 01 Name
ABD INSURANCE & FINANCIAL SERVICES
Ins Broker 01 Street Addr
305 WALNUT STREET
Ins Broker 01 City
REDWOOD CITY
Ins Broker 01 State
CA
Ins Broker 01 ZIP Code
94063
Ins Broker Comm Pd 01 Amount
$1,191
Ins Broker Fees Pd 01 Amount
$0
Ins Broker 01 Code
3
Row 3
Filing Id
91037023239036
Form Id
66773557
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
3030374300448050007
Ins Broker 01 Name
ABD INSURANCE & FINANCIAL SERVICES
Ins Broker 01 Street Addr
305 WALNUT STREET
Ins Broker 01 City
REDWOOD CITY
Ins Broker 01 State
CA
Ins Broker 01 ZIP Code
94063
Ins Broker Comm Pd 01 Amount
$8,635
Ins Broker Fees Pd 01 Amount
$0
Ins Broker 01 Code
3
Row 4
Filing Id
91037023239036
Form Id
66773553
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
3030374300448050003
Ins Broker 01 Name
ABD INSURANCE & FINANCIAL SERVICES
Ins Broker 01 Street Addr
305 WALNUT STREET
Ins Broker 01 City
REDWOOD CITY
Ins Broker 01 State
CA
Ins Broker 01 ZIP Code
94063
Ins Broker Comm Pd 01 Amount
$3,359
Ins Broker Fees Pd 01 Amount
$0
Ins Broker 01 Code
3
Row 5
Filing Id
91037023239036
Form Id
66773555
Page Id
1
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
3030374300448050005
Ins Broker Comm Pd 01 Amount
$0
Ins Broker Fees Pd 01 Amount
$0
Row 6
Filing Id
91037023239036
Form Id
66773556
Page Id
2
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
3030374300448050006
Ins Broker 01 Name
ABD INSURANCE & FINANCIAL SERVICES
Ins Broker 01 Street Addr
305 WALNUT STREET
Ins Broker 01 City
REDWOOD CITY
Ins Broker 01 State
CA
Ins Broker 01 ZIP Code
94063
Ins Broker Comm Pd 01 Amount
$3,738
Ins Broker Fees Pd 01 Amount
$0
Ins Broker 01 Code
3
Row 7
Ins Carrier Name: KAISER PERMANENTE
Filing Id
91037023239036
Form Id
66773557
Schedule A EIN
77-0449727
Schedule A Plan Num
501
Schedule A Plan Year Begin Date
2003-03-01
Schedule A Tax Period
20040229
Ins Carrier Name
KAISER PERMANENTE
Ins Carrier EIN
94-1340523
Ins Carrier Naic Code
00000
Ins Contract Num
SEE FOOTNOTE
Ins Prsn Covered End of year Count
57
Ins Policy From Date
2003-04-01
Ins Policy To Date
2004-02-29
Ins Broker Comm Total Amount
$8,635
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
AHJ
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
$275,884
Wlfr Acquis Cost Amount
$0
Row 8
Ins Carrier Name: METROPOLITAN LIFE INSURANCE COMPANY
Filing Id
91037023239036
Form Id
66773554
Schedule A EIN
77-0449727
Schedule A Plan Num
501
Schedule A Plan Year Begin Date
2003-03-01
Schedule A Tax Period
20040229
Ins Carrier Name
METROPOLITAN LIFE INSURANCE COMPANY
Ins Carrier EIN
13-5581829
Ins Carrier Naic Code
65978
Ins Contract Num
104117-G
Ins Prsn Covered End of year Count
725
Ins Policy From Date
2002-10-01
Ins Policy To Date
2003-09-30
Ins Broker Comm Total Amount
$18,626
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
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
$641,329
Wlfr Acquis Cost Amount
$0
Row 9
Ins Carrier Name: PACIFICARE BEHAVIORAL HEALTH OF CALIFORNIA
Filing Id
91037023239036
Form Id
66773551
Schedule A EIN
77-0449727
Schedule A Plan Num
501
Schedule A Plan Year Begin Date
2003-03-01
Schedule A Tax Period
20040229
Ins Carrier Name
PACIFICARE BEHAVIORAL HEALTH OF CALIFORNIA
Ins Carrier EIN
95-4166547
Ins Carrier Naic Code
00000
Ins Contract Num
471/A471
Ins Prsn Covered End of year Count
711
Ins Policy From Date
2003-03-01
Ins Policy To Date
2004-02-29
Ins Broker Comm Total Amount
$1,191
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
$24,638
Wlfr Acquis Cost Amount
$0
Row 10
Ins Carrier Name: TRANSAMERICA OCCIDENTAL LIFE INSURANCE
Filing Id
91037023239036
Form Id
66773553
Schedule A EIN
77-0449727
Schedule A Plan Num
501
Schedule A Plan Year Begin Date
2003-03-01
Schedule A Tax Period
20040229
Ins Carrier Name
TRANSAMERICA OCCIDENTAL LIFE INSURANCE
Ins Carrier EIN
95-1060502
Ins Carrier Naic Code
67121
Ins Contract Num
SEE FOOTNOTE
Ins Prsn Covered End of year Count
725
Ins Policy From Date
2003-03-01
Ins Policy To Date
2004-02-29
Ins Broker Comm Total Amount
$3,359
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
BTA AND VOLUNTARY 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
$3,673
Wlfr Acquis Cost Amount
$0
Row 11
Ins Carrier Name: GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
Filing Id
91037023239036
Form Id
66773555
Schedule A EIN
77-0449727
Schedule A Plan Num
501
Schedule A Plan Year Begin Date
2003-03-01
Schedule A Tax Period
20040229
Ins Carrier Name
GREAT-WEST LIFE & ANNUITY INSURANCE COMPANY
Ins Carrier EIN
84-0467907
Ins Carrier Naic Code
68322
Ins Contract Num
357322
Ins Prsn Covered End of year Count
666
Ins Policy From Date
2003-03-01
Ins Policy To Date
2004-02-29
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
$16,484
Wlfr Acquis Cost Amount
$0
Row 12
Ins Carrier Name: TUFTS ASSOCIATED HEALTH MAINTENANCE ORG. INC.
Filing Id
91037023239036
Form Id
66773556
Schedule A EIN
77-0449727
Schedule A Plan Num
501
Schedule A Plan Year Begin Date
2003-03-01
Schedule A Tax Period
20040229
Ins Carrier Name
TUFTS ASSOCIATED HEALTH MAINTENANCE ORG. INC.
Ins Carrier EIN
04-2674079
Ins Carrier Naic Code
95688
Ins Contract Num
88157000
Ins Prsn Covered End of year Count
44
Ins Policy From Date
2003-01-01
Ins Policy To Date
2003-12-31
Ins Broker Comm Total Amount
$3,738
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
AHJ
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
$126,951
Wlfr Acquis Cost Amount
$0

Schedule C

Schedule C Provider

Provider 1

Provider details

Source fields
Row 1
Filing Id
91037023239036
Page Id
1
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
3010376023239030002
Provider 01 Name
GREAT-WEST LIFE & ANNUITY INSURANCE
Provider 01 EIN
84-0467907
Provider 01 Position
CONTRACT ADMINISTRATOR
Provider 01 Relation
NONE
Provider 01 Salary Amount
$0
Provider 01 Fees Amount
$568,638
Provider 01 Srvc Code
12
Row 2
Filing Id
91037023239036
Page Id
3
Page Seq
0
Page Row Num
1
Row Num
0
Image Form Id
3010376023239030002

Schedule C Provider

Provider 2

Provider details

Source fields
Row 3
Filing Id
91037023239036
Schedule C EIN
77-0449727
Schedule C Plan number
501
Schedule C Plan Year Begin Date
2003-03-01
Schedule C Tax Period
20040229
Provider Total Comp Paid Amount
$0