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pdfSCHEDULE A
(Form 5500)
Insurance Information
Department of the Treasury
Internal Revenue Service
This schedule is required to be filed under section 104 of the
Employee Retirement Income Security Act of 1974.
OMB No. 1210-0110
MM / D D / Y Y Y Y
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This Form is Open to
Public Inspection.
MM / D D / Y Y Y Y
and ending
Name of plan
Plan sponsor's name as shown on line 2a of Form 5500
Employer Identification Number
NO
T
Part I
D
Three-digit
plan number
US
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B
▼
For calendar plan year 2008
or fiscal plan year beginning
File as an attachment to Form 5500.
Insurance companies are required to provide this information
pursuant to ERISA section 103(a)(2).
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Pension Benefit Guaranty Corporation
C
2008
▼
▼
Department of Labor
Employee Benefits Security
Administration
A
Official Use Only
Information Concerning Insurance Contract Coverage, Fees, and Commissions
DO
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:
Name of insurance carrier
(b) EIN
(c) NAIC code
(d) Contract or identification number
Approximate number of persons covered at end of policy or contract year
IN
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(e)
Policy or contract year
2
PU
RP
OS
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ON
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,
(a)
(f) From
▲
MM / D D / Y Y Y Y
▲
(g) To
MM / D D / Y Y Y Y
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
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Total fees paid / amount
.00
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.00
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For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 13505I Schedule A (Form 5500) 2008
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Schedule A (Form 5500) 2008
Page
2
(a)
Name and address of the agents, brokers or other persons to whom commissions or fees were paid
Name
Street Address
State
(c)
(b) Amount of commissions paid
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Fees paid / Amount
.00
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Organization
code
.00
NO
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DO
Name and address of the agents, brokers or other persons to whom commissions or fees were paid
Name
City
(c)
(b) Amount of commissions paid
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.00
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State
Zip Code
Fees paid / Amount
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PU
RP
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ON
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,
Street Address
(d) Fees paid / Purpose
(e)
Organization
code
(e)
Organization
code
.00
Name and address of the agents, brokers or other persons to whom commissions or fees were paid
Name
IN
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(a)
(e)
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(d) Fees paid / Purpose
(a)
Zip Code
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City
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Official Use Only
Street Address
City
State
(c)
(b) Amount of commissions paid
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Fees paid / Amount
.00
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(d) Fees paid / Purpose
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Zip Code
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.00
Schedule A (Form 5500) 2008
Page
3
Part II
Investment and Annuity Contract Information
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Official Use Only
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.
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.00
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.00
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.00
c Premiums due but unpaid at the end of the year .......................................................
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.00
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 .........................................................................
▲
▲
▲
.00
Current value of plan's interest under this contract in the general account at year end
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4
Current value of plan's interest under this contract in separate accounts at year end
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Contracts With Allocated Funds
a State the basis of premium rates
DO
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Specify nature of costs
e Type of contract
(2)
group deferred annuity
other (specify below)
IN
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f
individual policies
If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here ...
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(3)
(1)
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b Premiums paid to carrier ..............................................................................................
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Schedule A (Form 5500) 2008
Page
4
Official Use Only
deposit administration
(4)
other (specify below)
(2)
immediate participation guarantee
(3)
guaranteed investment
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(1)
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Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)
a Type of contract
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6
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b Balance at the end of the previous year ....................................................................
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.00
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.00
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c Additions:
(1) Contributions deposited during the year .........
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.00
Dividends and credits ......................................
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(3)
Interest credited during the year .....................
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.00
(4)
Transferred from separate account .................
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.00
(5)
Other (specify below) .......................................
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.00
(6)
Total additions ......................................................................................................
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.00
d Total of balance and additions (add b and c(6)) ........................................................
e Deductions:
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.00
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.00
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.00
ON
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(1)
DO
(2)
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.00
(2)
Administration charge made by carrier ...........
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.00
(3)
Transferred to separate account .....................
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.00
(4)
Other (specify below) .......................................
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.00
(5)
Total deductions ...................................................................................................
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IN
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Disbursed from fund to pay benefits or
purchase annuities during year .......................
f Balance at the end of the current year (subtract e(5) from d) ..................................
0
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Schedule A (Form 5500) 2008
Page
5
Official Use Only
Welfare Benefit Contract Information
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Part III
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 of this report.
Benefit and contract type (check all applicable boxes)
Health (other than
dental or vision)
(b)
Dental
(c)
Vision
(e)
Temporary disability
(accident and sickness)
(f)
Long-term disability
(g)
(i)
Stop loss (large deductible)
(j)
HMO contract
(k)
Supplemental
unemployment
(h)
Prescription drug
PPO contract
(l)
Indemnity contract
Other (specify below)
DO
▼
ON
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Experience-rated contracts
a Premiums:
(1) Amount received ..............................................
(3)
(4)
Increase (decrease)
in amount due but unpaid ...............................
PU
RP
OS
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(2)
Increase (decrease) in
unearned premium reserve .............................
▲
▲
▲
.00
▲
▲
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.00
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.00
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Earned ((1) + (2) - (3)) ........................................................................................
IN
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b Benefit charges:
(1) Claims paid ......................................................
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▲
▲
.00
▲
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▲
.00
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.00
(2)
Increase (decrease) in claim reserves ...........
(3)
Incurred claims (add (1) and (2)) ........................................................................
▲
▲
▲
.00
(4)
Claims charged ....................................................................................................
▲
▲
▲
.00
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Life Insurance
NO
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(m)
(d)
US
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(a)
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Schedule A (Form 5500) 2008
Page
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.00
(B) Administrative service or other fees .......
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.00
(C) Other specific acquisition costs ..............
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.00
(D) Other expenses .......................................
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.00
(E) Taxes ........................................................
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.00
(F) Charges for risks or other contingencies
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(G) Other retention charges ..........................
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.00
.00
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.00
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.00
d Status of policyholder reserves at end of year:
(1) Amount held to provide benefits after retirement ...............................................
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▲
▲
.00
(2) Claim reserves .....................................................................................................
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▲
▲
.00
Other reserves .....................................................................................................
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▲
▲
.00
e Dividends or retroactive rate refunds due.
(Do not include amount entered in c(2).) ...................................................................
▲
▲
▲
.00
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▲
.00
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▲
.00
(H) Total retention ..............................................................................................
paid in cash, or
2)
credited.) ..
(3)
IN
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Nonexperience-rated contracts:
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(These amounts were 1)
DO
(2) Dividends or retroactive rate refunds.
a Total premiums or subscription charges paid to carrier .............................................
b 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 below
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8 c Remainder of premium:
(1) Retention charges (on an accrual basis) -(A) Commissions ...........................................
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Official Use Only
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| File Type | application/pdf |
| File Title | 55500a |
| Subject | 55500a |
| Author | RhodHM |
| File Modified | 2008-06-05 |
| File Created | 2008-06-03 |