Form Schedule A Schedule A Insurance Information

Schedule A (Form 5500) 2012 v. 111118 Page 3 - 1 x

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

Insurance Information This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA).  File as an attachment to Form 5500.  Insurance companies are required to provide the information pursuant to ERISA section 103(a)(2).

OMB No. 1210-0110 2012 This Form is Open to Public Inspection

For calendar plan year 2012 or fiscal plan year beginning and ending

A Name of plan ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE FGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

B Three-digit plan number (PN) 

001

C Plan sponsor’s name as shown on line 2a of Form 5500 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE FGHI ABCDEFGHI

D Employer Identification Number (EIN) 012345678

Part I

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 Information:

(a) Name of insurance carrier

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

(b) EIN

(c) NAIC code

(d) Contract or identification number

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

Policy or contract year

(f) From

(g) To

012345678

ABCDE

ABCDE0123456789

1234567

YYYY-MM-DD

YYYY-MM-DD

2 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

123456789012345

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

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

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901

(b) Amount of sales and base commissions paid

Fees and other commissions paid

(e) Organization code

(c) Amount

(d) Purpose

-123456789012345

-123456789012345

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 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901

(b) Amount of sales and base commissions paid

Fees and other commissions paid

(e) Organization code

(c) Amount

(d) Purpose

-123456789012345

-123456789012345

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE

1

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

Schedule A (Form 5500) 2012 v. 111118

(a) Name and address of the agent, broker, or other person to whom commissions or fees were paid
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901
(b) Amount of sales and base commissions paid	Fees and other commissions paid		(e) Organization code
	(c) Amount	(d) Purpose
-123456789012345	-123456789012345	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 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901
(b) Amount of sales and base commissions paid	Fees and other commissions paid		(e) Organization code
	(c) Amount	(d) Purpose
-123456789012345	-123456789012345	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 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901
(b) Amount of sales and base commissions paid	Fees and other commissions paid		(e) Organization code
	(c) Amount	(d) Purpose
-123456789012345	-123456789012345	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 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901
(b) Amount of sales and base commissions paid	Fees and other commissions paid		(e) Organization code
	(c) Amount	(d) Purpose
-123456789012345	-123456789012345	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 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE 123456789 ABCDEFGHI ABCDEFGHI ABCDE CITY56789 ABCDEFGHI AB, ST 021345678901
(b) Amount of sales and base commissions paid	Fees and other commissions paid		(e) Organization code
	(c) Amount	(d) Purpose
-123456789012345	-123456789012345	ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE	1

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.

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

4

-123456789012345

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

5

-123456789012345

6 Contracts With Allocated Funds:

a State the basis of premium rates 

b Premiums paid to carrier

6b

-123456789012345

c Premiums due but unpaid at the end of the year

6c

-123456789012345

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.

6d

-123456789012345

Specify nature of costs 

e Type of contract: (1) X individual policies (2) X group deferred annuity

(3) X other (specify) 

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

X

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

a Type of contract:

(1) X deposit administration

(2) X immediate participation guarantee

(3) X guaranteed investment

(4) X other 

b Balance at the end of the previous year

7b

-123456789012345

c Additions: (1) Contributions deposited during the year

7c(1)

-123456789012345

(2) Dividends and credits

7c(2)

-123456789012345

(3) Interest credited during the year

7c(3)

-123456789012345

(4) Transferred from separate account

7c(4)

-123456789012345

(5) Other (specify below)

7c(5)

-123456789012345



(6)Total additions

7c(6)

-123456789012345

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

7d

-123456789012345

e Deductions:

(1) Disbursed from fund to pay benefits or purchase annuities during year

7e(1)

-123456789012345

(2) Administration charge made by carrier

7e(2)

-123456789012345

(3) Transferred to separate account

7e(3)

-123456789012345

(4) Other (specify below)

7e(4)

-123456789012345



(5) Total deductions

7e(5)

-123456789012345

f Balance at the end of the current year (subtract e(5) from d)

7f

-123456789012345

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 organizations(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.

8 Benefit and contract type (check all applicable boxes)

a X Health (other than dental or vision)

b X Dental

c X Vision

d X Life insurance

e X Temporary disability (accident and sickness)

f X Long-term disability

g X Supplemental unemployment

h X Prescription drug

i X Stop loss (large deductible)

j X HMO contract

k X PPO contract

l X Indemnity contract

m X Other (specify)  ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE

9 Experience-rated contracts:

a Premiums: (1) Amount received

9a(1)

-123456789012345

(2) Increase (decrease) in amount due but unpaid

9a(2)

-123456789012345

(3) Increase (decrease) in unearned premium reserve

9a(3)

-123456789012345

(4) Earned ((1) + (2) - (3))

9a(4)

-123456789012345

b Benefit charges (1) Claims paid

9b(1)

-123456789012345

(2) Increase (decrease) in claim reserves

9b(2)

-123456789012345

(3) Incurred claims (add (1) and (2))

9b(3)

123456789012345

(4) Claims charged

9b(4)

123456789012345

c Remainder of premium: (1) Retention charges (on an accrual basis) --

-123456789012345

(A) Commissions

9c(1)(A)

-123456789012345

(B) Administrative service or other fees

9c(1)(B)

-123456789012345

(C) Other specific acquisition costs

9c(1)(C)

-123456789012345

(D) Other expenses

9c(1)(D)

-123456789012345

(E) Taxes

9c(1)(E)

-123456789012345

(F) Charges for risks or other contingencies

9c(1)(F)

-123456789012345

(G) Other retention charges

9c(1)(G)

-123456789012345

(H) Total retention

9c(1)(H)

-123456789012345

(2) Dividends or retroactive rate refunds. (These amounts were X paid in cash, or X credited.)

9c(2)

-123456789012345

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

9d(1)

-123456789012345

(2) Claim reserves

9d(2)

-123456789012345

(3) Other reserves

9d(3)

-123456789012345

e Dividends or retroactive rate refunds due. (Do not include amount entered in c(2).)

9e

-123456789012345

10 Nonexperience-rated contracts:

a Total premiums or subscription charges paid to carrier

10a

-123456789012345

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.

10b

-123456789012345

Specify nature of costs 

Part IV

Provision of Information

11 Did the insurance company fail to provide any information necessary to complete Schedule A?

X Yes X No

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