Schedule A Insurance Information

SCHEDULE A

Insurance Information

OMB No. 1210-0110

(Form 5500)
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 (ERISA).

Department of Labor
Employee Benefits Security Administration

 File as an attachment to Form 5500.

Pension Benefit Guaranty Corporation

 Insurance companies are required to provide the information

2009
This Form is Open to Public
Inspection

pursuant to ERISA section 103(a)(2).
For calendar plan year 2009 or fiscal plan year beginning

and ending

A Name of plan
B Three-digit
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
001
plan number (PN)

FGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
D Employer Identification Number (EIN)
C Plan sponsor’s name as shown on line 2a of Form 5500.
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
012345678
FGHI ABCDEFGHI
Information Concerning Insurance Contract Coverage, Fees, and Commissions Provide information for each contract
Part I
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 Information:

(a) Name of insurance carrier

012345678
2

(c) NAIC
code

ABCDE

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

(d) Contract or
identification number

AF

(b) EIN

T

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

ABCDE0123456789

1234567

Policy or contract year
(f) From

(g) To

YYYY-MM-DD

YYYY-MM-DD

Insurance fee and commission information. Enter the total fees and total commissions paid. List in item 3 the agents, brokers, and other persons in
descending order of the amount paid.
(a) Total amount of commissions paid

(b) Total amount of fees paid

123456789012345

Persons receiving commissions and fees. (Complete as many entries as needed to report all persons).

R

3

123456789012345

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901

D

ABCDEFGHI
123456789
123456789
CITY56789

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

Fees and other commissions paid
(e) Organization code

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

1

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
123456789
123456789
CITY56789

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901
Fees and other commissions paid

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

(e) Organization code

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

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

1

Schedule A (Form 5500) 2009
v.092308.1

Page 2-

Schedule A (Form 5500) 2009

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
123456789
123456789
CITY56789

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901
Fees and other commissions paid

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(e) Organization
code

1

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901
Fees and other commissions paid

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(e) Organization
code

1

T

ABCDEFGHI
123456789
123456789
CITY56789

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901

AF

ABCDEFGHI
123456789
123456789
CITY56789

Fees and other commissions paid

(c) Amount

-123456789012345

-123456789012345

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(e) Organization
code

1

R

(b) Amount of sales and base
commissions paid

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901

D

ABCDEFGHI
123456789
123456789
CITY56789

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

Fees and other commissions paid
(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(e) Organization
code

1

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid

ABCDEFGHI
123456789
123456789
CITY56789

ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI

ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
ABCDEFGHI ABCDE
AB, ST 021345678901
Fees and other commissions paid

(b) Amount of sales and base
commissions paid

(c) Amount

-123456789012345

-123456789012345

(d) Purpose

ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

(e) Organization
code

1

Page 3

Schedule A (Form 5500) 2009

Investment and Annuity Contract Information

Part II

Current value of plan’s interest under this contract in separate accounts at year end ......................................................

b
c
d

e

Premiums paid to carrier ...........................................................................................................................................
Premiums due but unpaid at the end of the year ......................................................................................................
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 
Type of contract: (1)
(3)

f

X

X

other (specify)

individual policies

(2)

X

-123456789012345

6b
6c

-123456789012345
-123456789012345

6d

-123456789012345

group deferred annuity



If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here

 X

a

Type of contract:

(1)

b
c

deposit administration

(2)

guaranteed investment

(4)

X
X

immediate participation guarantee
other 

AF

(3)

X
X

T

Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)

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)..................................................................................



d
e

7b
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

-123456789012345

7c(6)
7d

-123456789012345
-123456789012345

Balance at the end of the previous year ...................................................................................................................

7c(1)
7c(2)
7c(3)
7c(4)
7c(5)

R

7

5

Contracts With Allocated Funds:
a State the basis of premium rates 

(6)Total additions ......................................................................................................................................................
Total of balance and additions (add b and c(6)). .......................................................................................................
Deductions:

D

4
5
6

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.
-123456789012345
Current value of plan’s interest under this contract in the general account at year end ....................................................
4

(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)...................................................................................

7e(1)
7e(2)
7e(3)
7e(4)

-123456789012345
-123456789012345
-123456789012345
-123456789012345



f

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

7e(5)
7f

-123456789012345
-123456789012345

Page 4

Schedule A (Form 5500) 2009

Part III

8

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 contracts cover individual employees,
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)

a X
e X
i X

Health (other than dental or vision)

mX

Other (specify)

Temporary disability (accident and sickness)

bX
f X
j X

cX
gX
kX

Dental
Long-term disability

Vision
Supplemental unemployment

dX
hX

Life insurance
Prescription drug

l X Indemnity contract
 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE

Stop loss (large deductible)

HMO contract

PPO contract

Experience-rated contracts:

a

Premiums: (1) Amount received.....................................................................

9a(1)

-123456789012345

b

-123456789012345
(2) Increase (decrease) in amount due but unpaid ....................................... 9a(2)
-123456789012345
(3) Increase (decrease) in unearned premium reserve................................. 9a(3)
(4) Earned ((1) + (2) - (3)) ...................................................................................................................................... 9a(4)
-123456789012345
Benefit charges (1) Claims paid ................................................................... 9b(1)

c

-123456789012345
(2) Increase (decrease) in claim reserves..................................................... 9b(2)
(3) Incurred claims (add (1) and (2)) ...................................................................................................................... 9b(3)
(4) Claims charged................................................................................................................................................. 9b(4)
-123456789012345
Remainder of premium: (1) Retention charges (on an accrual basis) --

AF

-123456789012345
(A) Commissions .................................................................................... 9c(1)(A)
-123456789012345
(B) Administrative service or other fees ................................................. 9c(1)(B)
9c(1)(C)
-123456789012345
(C) Other specific acquisition costs ........................................................
9c(1)(D)
-123456789012345
(D) Other expenses ................................................................................
9c(1)(E)
-123456789012345
(E) Taxes................................................................................................
9c(1)(F)
-123456789012345
(F) Charges for risks or other contingencies ..........................................
9c(1)(G)
-123456789012345
(G) Other retention charges ...................................................................
(H) Total retention ........................................................................................................................................... 9c(1)(H)

123456789012345
123456789012345

9c(2)
9d(1)
9d(2)
9d(3)
9e

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345

Total premiums or subscription charges paid to carrier ........................................................................................

10a

-123456789012345

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 

10b

-123456789012345

(2) Dividends or retroactive rate refunds. (These amounts were

X

paid in cash, or

X

credited.) .....................

Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement...................

e

(2) Claim reserves .................................................................................................................................................
(3) Other reserves .................................................................................................................................................
Dividends or retroactive rate refunds due. (Do not include amount entered in c(2).) ..........................................

Nonexperience-rated contracts:

a
b

R

d

D

10

-123456789012345

T

9

Welfare Benefit Contract Information

Provision of Information
Part IV
X Yes
X No
11 Did the insurance company fail to provide any information necessary to complete Schedule A? .............
12 If the answer to line 11 is “Yes,” specify the information not provided. ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE