Form 5500 Schedule 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

20121
This Form is Open to Public
Inspection

pursuant to ERISA section 103(a)(2).
For calendar plan year 20121 or fiscal plan year beginning
A Name of plan

and ending

B Three-digit

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
001
plan number (PN)

FGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
C Plan sponsor’s name as shown on line 2a of Form 5500
D Employer Identification Number (EIN)
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

ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
(b) EIN

012345678

(c) NAIC
code

ABCDE

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

(d) Contract or
identification number

ABCDE0123456789

1234567

Policy or contract year
(f) From

(g) To

YYYY-MM-DD

YYYY-MM-DD

2 Insurance fee and commission information. Enter the total fees and total commissions paid. List in item line 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
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
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

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

(e) Organization code

1

Schedule A (Form 5500)
20121 v. 120126012611

Schedule A (Form 5500) 20121 v. 120126

Page 2

- 1 x

(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
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
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
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
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) 20121 v. 120126

Investment and Annuity Contract Information

Part II

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
-123456789012345

4 Current value of plan’s interest under this contract in the general account at year end ............................................................ 4
5 Current value of plan’s interest under this contract in separate accounts at year end .............................................................. 5
6 Contracts With Allocated Funds:
a State the basis of premium rates 
b
c
d

Premiums paid to carrier .....................................................................................................................................................6b
Premiums due but unpaid at the end of the year ...............................................................................................................6c
If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or
6d
retention of the contract or policy, enter amount. ...............................................................................................................
Specify nature of costs 

e

Type of contract: (1)
(3)

X other (specify)

X individual policies

(2)

-123456789012345

X group deferred annuity



f If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here
 X
7 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)
(2) X immediate participation guarantee
a Type of contract:
(1) X deposit administration
(4) X other 
(3) X guaranteed investment

b
c

-123456789012345
-123456789012345

X

Balance at the end of the previous year .............................................................................................................................7b
Additions: (1) Contributions deposited during the year ............................................
7c(1)

7c(2)
(2) Dividends and credits............................................................................................
7c(3)
(3) Interest credited during the year...........................................................................
7c(4)
(4) Transferred from separate account ......................................................................
7c(5)
(5) Other (specify below) ............................................................................................

-123456789012345

-123456789012345
-123456789012345
-123456789012345
-123456789012345
-123456789012345



7c(6)
(6)Total additions .................................................................................................................................................................
d Total of balance and additions (add lines 7b and 7c(6)). ...................................................................................................7d
e Deductions:
-123456789012345
7e(1)
(1) Disbursed from fund to pay benefits or purchase annuities during year
-123456789012345
7e(2)
(2) Administration charge made by carrier .................................................................
-123456789012345
7e(3)
(3) Transferred to separate account ...........................................................................
-123456789012345
7e(4)
(4) Other (specify below) .............................................................................................

-123456789012345
-123456789012345

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

f

7e(5)
(5) Total deductions ..............................................................................................................................................................
Balance at the end of the current year (subtract line 7e(5) from line7d) ...........................................................................7f

-123456789012345
-123456789012345

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Page 4

Schedule A (Form 5500) 20121 v. 120126

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
e X Temporary disability (accident and sickness) f X Long-term disability
i X Stop loss (large deductible)
j X HMO contract
m X Other (specify)

c X Vision
g X Supplemental unemployment
k X PPO contract

 ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI

ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE
9 Experience-rated contracts:
a Premiums: (1) Amount received...........................................................................................
9a(1)

-123456789012345

b

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

c

-123456789012345
9b(2)
(2) Increase (decrease) in claim reserves ..........................................................................
9b(3)
(3) Incurred claims (add (1) and (2)) .....................................................................................................................................
9b(4)
(4) Claims charged ................................................................................................................................................................
-123456789012345
Remainder of premium: (1) Retention charges (on an accrual basis) --123456789012345
9c(1)(A)
(A) Commissions ..........................................................................................................
-123456789012345
9c(1)(B)
(B) Administrative service or other fees .......................................................................
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 .........................................................................................
9c(1)(H)
(H) Total retention ...........................................................................................................................................................
(2) Dividends or retroactive rate refunds. (These amounts were

X paid in cash, or X credited.) .................................
9c(2)

d Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement...............................
9d(1)

10

d X Life insurance
h X Prescription drug
l X Indemnity contract

9d(2)
(2) Claim reserves ................................................................................................................................................................
9d(3)
(3) Other reserves.................................................................................................................................................................
e Dividends or retroactive rate refunds due. (Do not include amount entered in line 9c(2).) ..............................................
9e
Nonexperience-rated contracts:
a Total premiums or subscription charges paid to carrier ......................................................................................................
10a
b If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or
10b
retention of the contract or policy, other than reported in Part I, item line 2 above, report amount. .................................
Specify nature of costs 

-123456789012345

123456789012345
123456789012345

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

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

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