Schedule A
- Row 1
- Filing Id
- 84037258009813
- Form Id
- 38136706
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 2040373258009060006
- Ins Broker 01 Name
- ARMSTRONG/ROBITAILLE INS. SVS. INC.
- Ins Broker 01 Street Addr
- 680 LANGSDORF DRIVE #100
- Ins Broker 01 City
- FULLERTON
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 928340000
- Ins Broker Comm Pd 01 Amount
- $4,356
- Ins Broker Fees Pd 01 Amount
- $0
- Row 2
- Filing Id
- 84037258009813
- Form Id
- 38136702
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 2040373258009060002
- Ins Broker 01 Name
- ARMSTRONG/ROBITAILLE INS. SVS INC
- Ins Broker 01 Street Addr
- 680 LANGSDORF DRIVE, #100
- Ins Broker 01 City
- FULLERTON
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 90017
- Ins Broker Comm Pd 01 Amount
- $5,270
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 3
- Filing Id
- 84037258009813
- Form Id
- 38136703
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 2040373258009060003
- Ins Broker 01 Name
- ARMSTRONG/ROBITAILLE INS. SVS. INC.
- Ins Broker 01 Street Addr
- 680 LANGSDORF DDRIVE #100
- Ins Broker 01 City
- FULLERTON
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 928340000
- Ins Broker Comm Pd 01 Amount
- $4,926
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 4
- Filing Id
- 84037258009813
- Form Id
- 38136704
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 2040373258009060004
- Ins Broker 01 Name
- ARMSTRONG/ROBITAILLE INSURANCE SVS.
- Ins Broker 01 Street Addr
- 680 LANGSDORF DRIVE #100
- Ins Broker 01 City
- FULLERTON
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 92834
- Ins Broker Comm Pd 01 Amount
- $1,007
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 5
- Filing Id
- 84037258009813
- Form Id
- 38136705
- Page Id
- 2
- Page Seq
- 0
- Page Row Num
- 1
- Row Num
- 0
- Image Form Id
- 2040373258009060005
- Ins Broker 01 Name
- ARMSTRONG/ROBITAILLE INS. SVS. INC.
- Ins Broker 01 Street Addr
- 680 LANGSDORF DRIVE #100
- Ins Broker 01 City
- FULLERTON
- Ins Broker 01 State
- CA
- Ins Broker 01 ZIP Code
- 928340000
- Ins Broker Comm Pd 01 Amount
- $9,575
- Ins Broker Fees Pd 01 Amount
- $0
- Ins Broker 01 Code
- 3
- Row 6
- Ins Carrier Name: HEALTHNET DENTAL AND VISION
- Filing Id
- 84037258009813
- Form Id
- 38136702
- Schedule A EIN
- 95-1644055
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2002-01-01
- Schedule A Tax Period
- 20021231
- Ins Carrier Name
- HEALTHNET DENTAL AND VISION
- Ins Carrier EIN
- 94-2197624
- Ins Carrier Naic Code
- 66141
- Ins Contract Num
- 1320
- Ins Prsn Covered End of year Count
- 198
- Ins Policy From Date
- 2001-01-01
- Ins Policy To Date
- 2002-12-31
- Ins Broker Comm Total Amount
- $5,270
- 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
- BC
- 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
- $61,619
- Wlfr Acquis Cost Amount
- $0
- Row 7
- Ins Carrier Name: KAISER PERMANENTE
- Filing Id
- 84037258009813
- Form Id
- 38136703
- Schedule A EIN
- 95-1644055
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2002-01-01
- Schedule A Tax Period
- 20021231
- Ins Carrier Name
- KAISER PERMANENTE
- Ins Carrier EIN
- 94-1340523
- Ins Carrier Naic Code
- 0000
- Ins Contract Num
- 1031290000
- Ins Prsn Covered End of year Count
- 76
- Ins Policy From Date
- 2002-01-01
- Ins Policy To Date
- 2002-12-31
- Ins Broker Comm Total Amount
- $4,926
- 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
- $113,986
- Wlfr Acquis Cost Amount
- $0
- Row 8
- Ins Carrier Name: UNITED OF OMAHA LIFE INSURANCE CO
- Filing Id
- 84037258009813
- Form Id
- 38136704
- Schedule A EIN
- 95-1644055
- Schedule A Plan Num
- 501
- Schedule A Plan Year Begin Date
- 2002-01-01
- Schedule A Tax Period
- 20021231
- Ins Carrier Name
- UNITED OF OMAHA LIFE INSURANCE CO
- Ins Carrier EIN
- 47-0322111
- Ins Carrier Naic Code
- 69868
- Ins Contract Num
- GVTL26T5
- Ins Prsn Covered End of year Count
- 26
- Ins Policy From Date
- 2002-01-01
- Ins Policy To Date
- 2002-12-31
- Ins Broker Comm Total Amount
- $1,007
- 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
- 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
- $6,714
- Wlfr Acquis Cost Amount
- $0
- Row 9
- Ins Carrier Name: UNUM LIFE INSURANCE COMPANY OF AMERICA
- Filing Id
- 84037258009813
- Form Id
- 38136706
- Schedule A EIN
- 95-1644055
- Schedule A Plan Num
- 3
- Schedule A Plan Year Begin Date
- 2002-01-01
- Schedule A Tax Period
- 20021231
- Ins Carrier Name
- UNUM LIFE INSURANCE COMPANY OF AMERICA
- Ins Carrier EIN
- 01-0278678
- Ins Carrier Naic Code
- 62235
- Ins Contract Num
- 501940
- Ins Prsn Covered End of year Count
- 160
- Ins Policy From Date
- 2002-01-01
- Ins Policy To Date
- 2002-12-31
- Ins Broker Comm Total Amount
- $4,356
- 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
- No
- 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
- $34,170
- Wlfr Acquis Cost Amount
- $0
- Row 10
- Ins Carrier Name: PACIFICARE
- Filing Id
- 84037258009813
- Form Id
- 38136705
- Schedule A EIN
- 95-1644055
- Schedule A Plan Num
- 3
- Schedule A Plan Year Begin Date
- 2002-01-01
- Schedule A Tax Period
- 20021231
- Ins Carrier Name
- PACIFICARE
- Ins Carrier EIN
- 95-2931460
- Ins Carrier Naic Code
- 70785
- Ins Contract Num
- 511108
- Ins Prsn Covered End of year Count
- 64
- Ins Policy From Date
- 2002-01-01
- Ins Policy To Date
- 2002-12-31
- Ins Broker Comm Total Amount
- $9,575
- 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
- $191,497
- Wlfr Acquis Cost Amount
- $0