Form Schedule A Schedule A Insurance Information

SCHEDULE A
(Form 5500)
Department of the Treasury
Internal Revenue Service
Department of Labor
Employee Benefits Security Administration

Insurance Information

Official Use Only

έ Insurance companies are required to provide this information

For calendar plan year 2007 or fiscal plan year beginning
Name of plan

pursuant to ERISA section 103(a)(2).
,
and ending

A

B
D

Plan sponsor's name as shown on line 2a of Form 5500

Part I

2007

έ File as an attachment to Form 5500.

Pension Benefit Guaranty Corporation

C

OMB No. 1210-0110

This schedule is required to be filed under section 104 of the
Employee Retirement Income Security Act of 1974.

This Form is Open to
Public Inspection.
,
Three-digit
plan number έ
Employer Identification Number

Information Concerning Insurance Contract Coverage, Fees, and Commissions
Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be
reported on a single Schedule A.

1

Coverage:
(a) Name of insurance carrier

(b) EIN

2

(c) NAIC
code

(d) Contract or
identification number

Policy or contract year
(f) From
(g) To

(e) Approximate number of persons
covered at end of policy or contract year

Insurance fees and commissions paid to agents, brokers and other persons. Enter the total fees and total commissions below and list agents,
brokers and other persons individually in descending order of the amount paid in the items on the following page(s) in Part I.

Totals
Total amount of commissions paid

Total fees paid / amount

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500.

0 6 0 7 0 0 0 1 0 E

v10.0

Schedule A (Form 5500) 2007

Schedule A (Form 5500) 2007

Page

2
Official Use Only

(a) Name and address of the agents, brokers or other
persons to whom commissions or fees were paid

(b) Amount of
commissions paid

(e)
Organization
code

Fees paid
(c) Amount

(d) Purpose

(a) Name and address of the agents, brokers or other
persons to whom commissions or fees were paid

(b) Amount of
commissions paid

(e)
Organization
code

Fees paid
(c) Amount

(d) Purpose

(a) Name and address of the agents, brokers or other
persons to whom commissions or fees were paid

(b) Amount of
commissions paid

(e)
Organization
code

Fees paid
(c) Amount

(d) Purpose

v10.0

0 6 0 7 0 0 0 2 0 F

Schedule A (Form 5500) 2007

Page

3
Official Use Only

Part II

Investment and Annuity Contract Information
Where individual contracts are provided, the entire group of such individual contracts with each carrier may be treated as a unit for
purposes of this report.

3
4
5

Current value of plan's interest under this contract in the general account at year end . . . . . . . . . . . . . . . . . . . . . . .
Current value of plan's interest under this contract in separate accounts at year end . . . . . . . . . . . . . . . . . . . . . . . .
Contracts With Allocated Funds
a State the basis of premium rates έ
b Premiums paid to carrier. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
c Premiums due but unpaid at the end of the year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
d If the carrier, service, or other organization incurred any specific costs in connection with the acquisition
or retention of the contract or policy, enter amount. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Specify nature of costs έ
e Type of contract (1) individual policies
(2)
group deferred annuity
(3)
other (specify) έ
f If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here . . . . . . . . . έ
6 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)
a Type of contract (1)
deposit administration
(2)
immediate participation guarantee
(3)
guaranteed investment
(4)
other (specify below)

έ

b
c

Balance at the end of the previous year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Additions: (1) Contributions deposited during the year . . . . . . . . . . . . . . . . . . . . .
(2) Dividends and credits. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(3) Interest credited during the year . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(4) Transferred from separate account . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(5) Other (specify below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

έ

d
e

(6) Total additions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Total of balance and additions (add b and c(6)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Deductions:
(1) Disbursed from fund to pay benefits or purchase annuities during year . . . . .
(2) Administration charge made by carrier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(3) Transferred to separate account. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(4) Other (specify below) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .

έ

f

(5) Total deductions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Balance at the end of the current year (subtract e(5) from d) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
v10.0

0 6 0 7 0 0 0 3 0 G

Schedule A (Form 5500) 2007

Page

4
Official Use Only

Part III

Welfare Benefit Contract Information
If more than one contract covers the same group of employees of the same employer(s) or members of the same
employee organization(s), the information may be combined for reporting purposes if such contracts are experience-rated
as a unit. Where individual contracts are provided, the entire group of such individual contracts with each carrier may be
treated as a unit for purposes on this report.

7

8
a

b

c

d

e
9
a
b

Benefit and contract type (check all applicable boxes)
a Health (other than dental or vision)
b Dental
c Vision
e Temporary disability (accident and sickness) f
Long-term disability
g Supplemental unemployment
i
Stop loss (large deductible)
j
HMO contract
k PPO contract
m Other (specify) έ
Experience-rated contracts
Premiums: (1) Amount received . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2) Increase (decrease) in amount due but unpaid . . . . . . . . . . . . . . . . . . . . . .
(3) Increase (decrease) in unearned premium reserve . . . . . . . . . . . . . . . . . . . .
(4) Earned ((1) + (2) - (3)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Benefit charges: (1) Claims paid . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2) Increase (decrease) in claim reserves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(3) Incurred claims (add (1) and (2)) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(4) Claims charged. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Remainder of premium: (1) Retention charges (on an accrual basis) -(A) Commissions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(B) Administrative service or other fees. . . . . . . . . . . . . . . . . . . . . . . . . . . .
(C) Other specific acquisition costs . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(D) Other expenses . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(E) Taxes . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(F) Charges for risks or other contingencies . . . . . . . . . . . . . . . . . . . . . . . .
(G) Other retention charges . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(H) Total retention . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(2) Dividends or retroactive rate refunds. (These amounts were
paid in cash, or
credited.) . . . . . . . . . . .
Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement . . . . . . . . . . .
(2) Claim reserves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
(3) Other reserves . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
Dividends or retroactive rate refunds due. (Do not include amount entered in c(2).) . . . . . . . . . . . . . . . . . . . . . . .
Nonexperience-rated contracts:
Total premiums or subscription charges paid to carrier . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
If the carrier, service, or other organization incurred any specific costs in connection with the acquisition
or retention of the contract or policy, other than reported in Part I, item 2 above, report amount . . . . . . . . . . . . . .
Specify nature of costs έ

v10.0

0 6 0 7 0 0 0 4 0 H

d
h
l

Life Insurance
Prescription drug
Indemnity contract