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pdfSCHEDULE 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
20152016
This Form is Open to Public
Inspection
pursuant to ERISA section 103(a)(2).
For calendar plan year 2015 2016 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
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 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
(e) Organization code
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
(d) Purpose
(e) Organization code
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE
For Paperwork Reduction Act Notice and OMB Control Numbers, see the Iinstructions for Form 5500.
1
Schedule A (Form 5500) 2015
2016 v. 150123160205
Page 2
Schedule A (Form 5500) 20152016
–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) 20165
Part II
4
5
6
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.
123456789012345
Current value of plan’s interest under this contract in the general account at year end ...............................................
4
123456789012345
Current value of plan’s interest under this contract in separate accounts at year end ..................................................
5
Contracts With Allocated Funds:
a State the basis of premium rates
b
c
d
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
e
Type of contract: (1)
(3)
f
X other (specify)
X individual policies
(2)
6b
6c
-123456789012345
-123456789012345
6d
-123456789012345
X group deferred annuity
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)
(2) X immediate participation guarantee
a Type of contract:
(1) X deposit administration
(4) X other
(3) X guaranteed investment
b
c
Balance at the end of the previous year .............................................................................................................
7b
-123456789012345
Additions: (1) Contributions deposited during the year ...............................
7c(1)
(2) Dividends and credits.............................................................................
(3) Interest credited during the year.............................................................
(4) Transferred from separate account ........................................................
(5) Other (specify below) .............................................................................
7c(2)
7c(3)
7c(4)
7c(5)
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
f
(5) Total deductions ............................................................................................................................................
Balance at the end of the current year (subtract line 7e(5) from line 7d) .............................................................
7e(5)
7f
123456789012345
123456789012345
Page 4
Schedule A (Form 5500) 2016
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
d X Life insurance
h X Prescription drug
l X Indemnity contract
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI
ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE
9 Experience-rated contracts:
a Premiums: (1) Amount received ................................................................
9a(1)
9a(2)
9a(3)
-123456789012345
-123456789012345
-123456789012345
123456789012345
b
(2) Increase (decrease) in amount due but unpaid ...................................
(3) Increase (decrease) in unearned premium reserve .............................
9a(4)
(4) Earned ((1) + (2) - (3)) ...............................................................................................................................................
-123456789012345
Benefit charges (1) Claims paid ...............................................................
9b(1)
123456789012345
123456789012345
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
(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)
9c(1)(H)
(H) Total retention.....................................................................................................................................
(2) Dividends or retroactive rate refunds. (These amounts were
X paid in cash, or X credited.)..................
d Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement ...............
10
(2) Claim reserves ..........................................................................................................................................
(3) Other reserves ..........................................................................................................................................
e Dividends or retroactive rate refunds due. (Do not include amount entered in line 9c(2).) ..............................
Nonexperience-rated contracts:
a Total premiums or subscription charges paid to carrier ...................................................................................
9c(2)
9d(1)
9d(2)
9d(3)
9e
10a
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, line 2 above, report amount. .........................
Specify nature of costs.
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
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ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
ABCDEFGHI
10b
123456789012345
123456789012345
123456789012345
123456789012345
123456789012345
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ABCDEFGHI
ABCDEFGHI
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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
ABCD ABC
ABCD
ABCD
ABCD
ABCD
ABCD
ABCD
ABCD
ABCD
ABCD
| File Type | application/pdf |
| File Title | Form 5500 |
| Author | Bruce Silver |
| File Modified | 2016-10-11 |
| File Created | 2016-10-11 |