Schedule A
- Row 1
- Filing Id
- 56037313157530
- Form Id
- 530588
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 30370313157030002
- Ins Broker 01 Name
- THE PRECEPT GROUP
- Ins Broker 01 Street Addr
- 1500 QUAIL STREET
- Ins Broker 01 City
- NEWPORT BEACH
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 92660
- Ins Broker Comm Pd 01 Amount
- $7,628
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 2
- Filing Id
- 56037313157530
- Form Id
- 530589
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 30370313157030003
- Ins Broker 01 Name
- WEST COAST INSURANCE SERVICES
- Ins Broker 01 Street Addr
- PO BOX 189
- Ins Broker 01 City
- VANCOUVER
- Ins Broker 01 State
- WA
- Ins Broker 01 ZIP Code
- 98666
- Ins Broker Comm Pd 01 Amount
- $201
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 3
- Filing Id
- 56037313157530
- Form Id
- 530590
- Page Id
- 1
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 30370313157030004
- Ins Broker Comm Pd 01 Amount
- $0
- Ins Broker Fees Pd 01 Amount
- $0
- Row 4
- Filing Id
- 56037313157530
- Form Id
- 530591
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 30370313157030005
- Ins Broker 01 Name
- THE RRECEPT GROUP
- Ins Broker 01 Street Addr
- 1500 QUAIL STREET
- Ins Broker 01 City
- NEWPORT BEACH
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 92660
- Ins Broker Comm Pd 01 Amount
- $552
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 5
- Ins Carrier Name: PROVIDENCE HEALTH PLAN
- Filing Id
- 56037313157530
- Form Id
- 530588
- Schedule A EIN
- 91-1348425
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 1999-01-01
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- PROVIDENCE HEALTH PLAN
- Ins Carrier EIN
- 93-0863097
- Ins Carrier Naic Code
- 95005
- Ins Contract Num
- G01101
- Ins Prsn Covered End of year Count
- 123
- Ins Policy From Date
- 1999-01-01
- Ins Policy To Date
- 1999-12-31
- Ins Broker Comm Total Amount
- $7,628
- 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
- AH
- 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
- $117,356
- Wlfr Acquis Cost Amount
- $0
- Row 6
- Ins Carrier Name: KAISER PERMANENTE NORTHWEST REGION
- Filing Id
- 56037313157530
- Form Id
- 530589
- Schedule A EIN
- 91-1348425
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 1999-01-01
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- KAISER PERMANENTE NORTHWEST REGION
- Ins Carrier EIN
- 93-0798039
- Ins Carrier Naic Code
- 95540
- Ins Contract Num
- 7701AA
- Ins Prsn Covered End of year Count
- 34
- Ins Policy From Date
- 1999-01-01
- Ins Policy To Date
- 1999-03-31
- Ins Broker Comm Total Amount
- $201
- 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
- AH
- 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
- $29,171
- Wlfr Acquis Cost Amount
- $0
- Row 7
- Ins Carrier Name: REGENCE BLUE CROSS BLUE SHIELD OF OREGON
- Filing Id
- 56037313157530
- Form Id
- 530590
- Schedule A EIN
- 91-1348425
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 1999-01-01
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- REGENCE BLUE CROSS BLUE SHIELD OF OREGON
- Ins Carrier EIN
- 93-0238155
- Ins Carrier Naic Code
- 54933
- Ins Contract Num
- 062614000
- Ins Prsn Covered End of year Count
- 115
- 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
- ABH
- Wlfr Premium Rcvd Amount
- $0
- Wlfr Unpaid Due Amount
- $0
- Wlfr Reserve Amount
- $0
- Wlfr Total Earned Prem Amount
- $0
- Wlfr Claims Paid Amount
- $96,683
- Wlfr Incr Reserve Amount
- $0
- Wlfr Incurred Claim Amount
- $96,683
- Wlfr Claims Chrgd Amount
- $0
- Wlfr Ret Commissions Amount
- $0
- Wlfr Ret Admin Amount
- $13,959
- 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
- $13,959
- 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
- $21,549
- Wlfr Acquis Cost Amount
- $0
- Row 8
- Ins Carrier Name: WASHINGTON DENTAL SERVICE
- Filing Id
- 56037313157530
- Form Id
- 530591
- Schedule A EIN
- 91-1348425
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 1999-01-01
- Schedule A Tax Period
- 19991231
- Ins Carrier Name
- WASHINGTON DENTAL SERVICE
- Ins Carrier EIN
- 91-0621480
- Ins Carrier Naic Code
- 47341
- Ins Contract Num
- 725
- Ins Prsn Covered End of year Count
- 184
- Ins Policy From Date
- 1999-01-01
- Ins Policy To Date
- 1999-03-31
- Ins Broker Comm Total Amount
- $552
- 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
- $80,693
- Wlfr Unpaid Due Amount
- $0
- Wlfr Reserve Amount
- $0
- Wlfr Total Earned Prem Amount
- $80,693
- Wlfr Claims Paid Amount
- $77,165
- Wlfr Incr Reserve Amount
- $0
- Wlfr Incurred Claim Amount
- $0
- Wlfr Claims Chrgd Amount
- $0
- Wlfr Ret Commissions Amount
- $552
- Wlfr Ret Admin Amount
- $2,976
- 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
- $3,528
- 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
- $0
- Wlfr Acquis Cost Amount
- $0