Schedule A
- Row 1
- Filing Id
- 84037108393792
- Form Id
- 14645190
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 40372108393040002
- Ins Broker 01 Name
- WOODRUFF-SAWYER & CO.
- Ins Broker 01 Street Addr
- 220 BUSH STREET, 7TH FLOOR
- Ins Broker 01 City
- SAN FRANCISCO
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 94104
- Ins Broker Comm Pd 01 Amount
- $4,657
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 2
- Filing Id
- 84037108393792
- Form Id
- 14645193
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 40372108393040003
- Ins Broker 01 Name
- WOODRUFF-SAWYER & CO.
- Ins Broker 01 Street Addr
- 220 BUSH STREET, 7TH FLOOR
- Ins Broker 01 City
- SAN FRANCISCO
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 941043509
- Ins Broker Comm Pd 01 Amount
- $963
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 3
- Ins Carrier Name: UNUM
- Filing Id
- 84037108393792
- Form Id
- 14645190
- Schedule A EIN
- 94-3050031
- Schedule A Plan Num
- 504
- Schedule A Plan Year Begin Date
- 2000-07-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- UNUM
- Ins Carrier EIN
- 01-0278678
- Ins Carrier Naic Code
- 62235
- Ins Contract Num
- 350464
- Ins Prsn Covered End of year Count
- 0
- Ins Policy From Date
- 1999-10-01
- Ins Policy To Date
- 2000-09-30
- Ins Broker Comm Total Amount
- $4,657
- 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
- DEM
- Wlfr Type Bnft Oth Text
- ACCIDENTAL DEATH AND 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
- $68,751
- Wlfr Acquis Cost Amount
- $0
- Row 4
- Ins Carrier Name: UNUM
- Filing Id
- 84037108393792
- Form Id
- 14645193
- Schedule A EIN
- 94-3050031
- Schedule A Plan Num
- 504
- Schedule A Plan Year Begin Date
- 2000-07-01
- Schedule A Tax Period
- 20001231
- Ins Carrier Name
- UNUM
- Ins Carrier EIN
- 01-0278678
- Ins Carrier Naic Code
- 62235
- Ins Contract Num
- 350464
- Ins Prsn Covered End of year Count
- 0
- Ins Policy From Date
- 2000-10-01
- Ins Policy To Date
- 2000-12-31
- Ins Broker Comm Total Amount
- $963
- 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
- E
- 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
- $13,791
- Wlfr Acquis Cost Amount
- $0