Form 8925 Report of Employer-Owned Life Insurance Contracts

Caution: DRAFT FORM
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It is subject to change and OMB approval before it
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8925

Form
(December 2009)

Report of Employer-Owned Life Insurance Contracts

Department of the Treasury
Internal Revenue Service (99)

Name(s) shown on return
Name of policyholder, if different from above
Type of business

© Attach

to the policyholder’s tax return—See instructions.

Attachment
Sequence No.

160

Identifying number

f
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a
9
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a
2
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D /24
6
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Identifying number, if different from above

1
2

Enter the number of employees the policyholder had at the end of the tax year . . . . .
Enter the number of employees included on line 1 who were insured at the end of the tax
year under the policyholder’s employer-owned life insurance contract(s) issued after August
17, 2006. See Section 1035 exchanges below for an exception . . . . . . . . . .

3

Enter the total amount of employer-owned life insurance in force at the end of the tax year
for employees who were insured under the contract(s) specified on line 2 . . . . . . .

4a

OMB No. 1545-2089

Does the policyholder have a valid consent (see instructions) for each
employee included on line 2? . . . . . . . . . . . . . . .
Yes
No
b If “No,” enter the number of employees included on line 2 for whom the policyholder does
not have a valid consent . . . . . . . . . . . . . . . . . . . . . . .

For Paperwork Reduction Act Notice, see page 2.

Cat. No. 37737A

1

2
3

4b

Form

8925

(12-2009)