Form Request for Covera Request for Covera Request for Coverage Determination

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Request for Coverage Determination

OMB No: 1212-00XX
Expires: XX/XX

This form is used by a plan administrator or plan sponsor of a plan to request that the Pension Benefit Guaranty Corporation
determine whether a plan is covered under title IV of the Employee Retirement Income Security Act of 1974 (ERISA). For questions
about this form, send an email to [email protected] or call 800-736-2444 or 202-326-4242.

Part I. Identifying Information

_____________

U

_____________________________________________
Plan name

_______________________________________________
Name of authorized contact person for filer

_______________________________________________
Plan administrator

_______________________________________________
Title of contact

_______________________________________________
Street address of plan administrator

_______________________________________________
Street address of contact

_______________________________________________
City, State, and Zip Code of plan administrator

_______________________________________________
City, State, and Zip Code of contact

_______________________________________________
Plan sponsor (if different from plan administrator)

_______________________________________________
Email address of contact

_______________________________________________
Street address of plan sponsor

______________________________________ ________
Telephone number of contact
Ext.

_______________________________________________
City, State, and Zip Code of plan sponsor

Filer is:

EIN of plan sponsor

□ Plan administrator
□ Plan sponsor

Plan number

Part II. All Plans, Required Information

U

1

This request is for a determination of □ non-coverage or □ coverage under title IV of ERISA.

2

Check the applicable box(es) that apply to the coverage determination request (see instructions).
□ Substantial owners plan
□ Other exemption under section 4021(b) of ERISA
□ Small professional service employer plan □ Puerto Rico-based plan
□ Church plan
□ Other

3 Has PBGC issued a coverage determination for the plan before? □ Yes □ No
If yes, provide an explanation in Part VIII, Narrative Information of the plan’s changed circumstances from
those of the prior determination.

Request for Coverage Determination

Part II. All Plans, Required Information (continued)
4 The plan is □ already established or □ proposed but not yet established.
A plan that is proposed but not yet established may use this form to request an opinion from PBGC under a
pilot program (see instructions).
5 Check the box to confirm that the required item is attached.
□ The plan document
□ Correspondence with the Internal Revenue Service that is relevant to the plan’s status as a qualified
plan under Internal Revenue Code (Code) section 401(a)
Part III. Substantial Owners Plans, Required Information
1

Does the plan cover an individual who is not a substantial owner?
□ Yes □ No (If yes, the plan is likely not eligible for this exemption.)

2

What is the organizational structure of the plan sponsor?
□ Corporation □ Limited liability company (see question below) □ Partnership □ Sole proprietorship
□ Other (explain in explain in Part VIII, Narrative Information)
If the plan sponsor is a limited liability company, how is it treated for federal tax purposes?
□ Corporation □ Partnership □ Disregarded entity (part of its owner’s tax return)

3
4

Check the box to confirm that the required item is attached.
□ List of the names of all the participants (active, retired, and term vested) in the plan
□ Documents showing the percentage of ownership interest that each participant currently holds or
has held in the plan sponsor during the 60 months before the completion of this form
□ Documents reflecting any stock options for the plan sponsor (if the plan sponsor is a corporation)
□ The partnership agreement or other document (e.g. partnership meeting minutes, state
government filing) naming the partners (if the plan sponsor is a partnership)
□ Documents indicating whether the owner’s spouse is an employee, director, or manager (if (1) the
plan sponsor is a corporation or is taxed as a corporation and (2) the plan covers only the owner and
the owner’s spouse)
□ A description of any family relationships between the owner(s) of the plan sponsor and other
participants of the plan and the names and the dates of birth of the owners’ children (if such family
relationships exist)
□ Documents (e.g. a spreadsheet) showing dates and amounts paid to participants (providing their
names) within the past six years
□ Date of termination or planned date of termination (if the plan has or will be terminated)

5 □ Check the box to confirm reading Part III of the instructions listing additional required items that
PBGC may request.

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Request for Coverage Determination

Part IV. Small Professional Service Employer Plans, Required Information
1
2

Has the plan at any time since September 2, 1974, had more than 25 active participants?
□ Yes □ No (If yes, the plan is not eligible for this exemption.)
The website of the plan sponsor (if any): ___________________________

3

Check the box to confirm that the required item is attached.
□ Name, principal business, services performed, and organizational structure of every employer
involved in establishing and maintaining the plan
□ A percentage breakdown of the services performed, including the amount of revenue generated
from each service (if the plan sponsor provides multiple services)
□ Names, occupations, levels of education, and percentages and periods of ownership of all current
owners of the plan sponsor
□ Names, occupations, levels of education, and titles of all individuals who control, manage, or direct
the plan sponsor
□ Educational requirements for the plan sponsor’s profession and qualifications such as course work,
graduate school, specific state licenses, or similar requirements

4

□ Check this box to confirm reading of Part IV of the instructions listing additional required items that

PBGC may request.

Part V. Church Plans, Required Information
1

Has the plan made an election under Code section 410(d)? □ Yes □ No

2

Does the plan wish to have title IV of ERISA apply to it? □ Yes □ No

3

Check the box to confirm that the required item is attached.
□ The determination from the Internal Revenue Service that the plan is a church plan under Code
section 414(e)
□ The election made under Code section 410(d)? (if such election has been made)

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Request for Coverage Determination

Part VI. Puerto Rico-Based Plans, Required Information
1
2
3

Does each participant in the plan either reside or work primarily in Puerto Rico?
□ Yes □ No
Has the plan made an election under section 1022(i)(2) of ERISA and 26 CFR 1.401(a)-50?
□ Yes □ No
Check the box to confirm that the required item is attached.
□ Documentation of the election made under 26 CFR 1.401(a)-50 (if such an election has been made)
□ The trust document or agreement, group annuity contract, or other financial document(s) funding
the plan
□ The name and location of the trust and trustee (if the plan is funded by a trust)
□ The name of the contract holder (if the plan is funded by a group annuity contract)
□ The master trust agreement (if the plan is part of a master trust/ agreement)
□ Documentation appointing the plan administrator
□ Whether the administrator is an individual, entity, or committee
□ The qualification letter(s) from the Puerto Rico Department of Treasury
□ Documentation transferring the plan trust to Puerto Rico from elsewhere in the United States and
the date when this transfer occurred (if such a transfer took place)

Part VII. Missing Information
_____________
If any applicable item listed above is not attached or the request for coverage determination is otherwise
lacking information, explain here. If needed, attach extra pages.

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Request for Coverage Determination

Part VIII. Narrative Information (Optional)
In the space below, include a supporting statement. If needed, attach extra pages.

Part IX. Certification
I have personal knowledge of the statements, information, records, and documents provided in the form and
attachments.
All of the statements and information I have provided or will provide to the Pension Benefit Guaranty
Corporation regarding this filing request are true, correct, and complete to the best of my knowledge.
I understand that knowingly and willfully concealing material facts or making or providing materially false,
fictitious, or fraudulent statements or representations to the Pension Benefit Guaranty Corporation may be
punishable under 18 U.S.C. § 1001.
___________________________________ ____________________________________

Signature of Individual Submitting Form

Name and Title of Individual Submitting Form

______________________________________ _______________________________________
Phone Number of Individual Submitting Form

Employer of Individual Submitting Form

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