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pdfCUMULATIVE CHANGES
SCHEDULE 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.
Pension Benefit Guaranty Corporation
For calendar plan year 2008
or fiscal plan year beginning
2008
File as an attachment to Form 5500.
Insurance companies are required to provide this information
pursuant to ERISA section 103(a)(2).
MM / D D / Y Y Y Y
and ending
This Form is Open to
Public Inspection.
MM / D D / Y Y Y Y
Name of plan
Plan sponsor's name as shown on line 2a of Form 5500
Part I
Three-digit
plan number
D
Employer Identification Number
▼
B
Information Concerning Insurance Contract Coverage, Fees, and Commissions
O
O
F
C
OMB No. 1210-0110
▼
▼
Department of Labor
Employee Benefits Security
Administration
A
Official Use Only
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
PR
(a)
(c) NAIC code
(e)
Approximate number of persons covered at end of policy or contract year
Policy or contract year
2
3R
(d) Contract or identification number
D
(b) EIN
(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
▲
▲
Total fees paid / amount
.00
▲
▲
▲
▲
.00
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
Official Use Only
(a)
Name and address of the agents, brokers or other persons to whom commissions or fees were paid
Name
Street Address
City
State
(c)
(b) Amount of commissions paid
▲
▲
Fees paid / Amount
.00
▲
Zip Code
(e)
▲
▲
▲
Organization
code
.00
(a)
O
O
F
(d) Fees paid / Purpose
Name and address of the agents, brokers or other persons to whom commissions or fees were paid
Name
Street Address
State
PR
City
(c)
(b) Amount of commissions paid
▲
▲
Fees paid / Amount
.00
▲
▲
▲
▲
(e)
Organization
code
(e)
Organization
code
.00
(a)
3R
D
(d) Fees paid / Purpose
Zip Code
Name and address of the agents, brokers or other persons to whom commissions or fees were paid
Name
Street Address
City
State
(c)
(b) Amount of commissions paid
▲
▲
Fees paid / Amount
.00
▲
Zip Code
▲
▲
▲
.00
(d) Fees paid / Purpose
0
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0
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F
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Schedule A (Form 5500) 2008
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
Current value of plan's interest under this contract in the general account at year end
▲
▲
▲
.00
4
Current value of plan's interest under this contract in separate accounts at year end
▲
▲
▲
.00
O
O
F
Contracts With Allocated Funds
a State the basis of premium rates
▼
▲
▲
▲
.00
c Premiums due but unpaid at the end of the year .......................................................
▲
▲
▲
.00
▲
▲
▲
.00
PR
b Premiums paid to carrier ..............................................................................................
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 .........................................................................
e Type of contract
(1)
individual policies
(2)
group deferred annuity
other (specify below)
▼
(3)
3R
▼
D
Specify nature of costs
f
If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here ...
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▼
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Schedule A (Form 5500) 2008
Page
4
Official Use Only
Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)
a Type of contract
(1)
deposit administration
(4)
other (specify below)
(2)
immediate participation guarantee
(3)
guaranteed investment
▼
6
c Additions:
(1) Contributions deposited during the year .........
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
.00
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
O
O
F
▲
(3)
Interest credited during the year .....................
(4)
Transferred from separate account .................
(5)
Other (specify below) .......................................
(6)
Total additions ......................................................................................................
PR
Dividends and credits ......................................
D
▼
▲
▲
(2)
3R
d Total of balance and additions (add b and c(6)) ........................................................
e Deductions:
(1)
▲
▲
b Balance at the end of the previous year ....................................................................
▲
▲
▲
.00
(2)
Administration charge made by carrier ...........
▲
▲
▲
.00
(3)
Transferred to separate account .....................
▲
▲
▲
.00
(4)
Other (specify below) .......................................
▲
▲
▲
.00
(5)
Total deductions ...................................................................................................
▲
▲
▲
.00
f Balance at the end of the current year (subtract e(5) from d) ..................................
▲
▲
▲
.00
▼
Disbursed from fund to pay benefits or
purchase annuities during year .......................
0
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Schedule A (Form 5500) 2008
Page
5
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 of this report.
7
Benefit and contract type (check all applicable boxes)
(a)
Health (other than
dental or vision)
(b)
Dental
(c)
Vision
(d)
Life Insurance
(e)
Temporary disability
(accident and sickness)
(f)
Long-term disability
(g)
Supplemental
unemployment
(h)
Prescription drug
(i)
Stop loss (large deductible)
(j)
HMO contract
(k)
PPO contract
(l)
O
O
F
Other (specify below)
▼
(m)
Experience-rated contracts
a Premiums:
(1) Amount received ..............................................
(4)
PR
(3)
▲
▲
.00
Increase (decrease)
in amount due but unpaid ...............................
▲
▲
▲
.00
Increase (decrease) in
unearned premium reserve .............................
▲
▲
▲
.00
D
(2)
▲
▲
Earned ((1) + (2) - (3)) ........................................................................................
3R
8
Indemnity contract
b Benefit charges:
(1) Claims paid ......................................................
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
.00
(2)
Increase (decrease) in claim reserves ...........
(3)
Incurred claims (add (1) and (2)) ........................................................................
▲
▲
▲
.00
(4)
Claims charged ....................................................................................................
▲
▲
▲
.00
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Schedule A (Form 5500) 2008
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Official Use Only
▲
▲
▲
.00
(B) Administrative service or other fees .......
▲
▲
▲
.00
(C) Other specific acquisition costs ..............
▲
▲
▲
.00
(D) Other expenses .......................................
▲
▲
▲
.00
(E) Taxes ........................................................
▲
▲
▲
.00
(F) Charges for risks or other contingencies
▲
▲
▲
.00
(G) Other retention charges ..........................
▲
▲
▲
.00
O
O
F
8 c Remainder of premium:
(1) Retention charges (on an accrual basis) -(A) Commissions ...........................................
▲
▲
▲
.00
credited.) ..
▲
▲
▲
.00
d Status of policyholder reserves at end of year:
(1) Amount held to provide benefits after retirement ...............................................
▲
▲
▲
.00
(2) Claim reserves .....................................................................................................
▲
▲
▲
.00
(3)
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
▲
▲
▲
.00
(H) Total retention ..............................................................................................
(2) Dividends or retroactive rate refunds.
paid in cash, or
2)
PR
(These amounts were 1)
D
Other reserves .....................................................................................................
9
3R
e Dividends or retroactive rate refunds due.
(Do not include amount entered in c(2).) ...................................................................
Nonexperience-rated contracts:
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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| File Type | application/pdf |
| File Title | 85500a.pmd |
| Author | rhodhm |
| File Modified | 2008-06-27 |
| File Created | 2008-05-01 |