Part I - Information Concerning Insurance Contract
2009 Instructions for Schedule A
Coverage, Fees, and Commissions
Line 1(c). Enter the code number assigned by the National
Association of Insurance Commissioners (NAIC) to the
insurance company. If none has been assigned, enter zeros
(-0-) in the spaces provided.
Line 1(d). If individual policies with the same carrier are
grouped as a unit for purposes of this report, and the group
Who Must File
does not have one identification number, you may use the
contract or identification number of one of the individual
Schedule A (Form 5500) must be attached to the Form 5500
contracts, provided this number is used consistently to report
filed for every defined benefit pension plan, defined contribution
these contracts as a group and the plan administrator maintains
pension plan, and welfare benefit plan required to file a Form
the records necessary to disclose all the individual contract
5500 if any benefits under the plan are provided by an
numbers in the group upon request. Use separate Schedules A
insurance company, insurance service, or other similar
to report individual contracts that cannot be grouped as a unit.
organization (such as Blue Cross, Blue Shield, or a health
maintenance organization). This includes investment contracts
Line 1(e). Since plan coverage may fluctuate during the year,
with insurance companies such as guaranteed investment
the administrator should estimate the number of persons that
contracts (GICs). In addition, Schedules A must be attached to
were covered by the contract at the end of the policy or contract
a Form 5500 filed for GIAs, MTIAs, and 103-12 IEs for each
year. Where contracts covering individual employees are
insurance or annuity contract held in the MTIA, or 103-12 IE or
grouped, compute entries as of the end of the plan year.
by the GIA.
Lines 1(f) and (g). Enter the beginning and ending dates of
the policy year for the contract identified in 1(d). Leave 1(f)
If Form 5500 line 9a(1), 9a(2), 9b(1), or 9b(2) is
blank if separate contracts covering individual employees are
checked, indicating that either the plan funding
arrangement or plan benefit arrangement includes an
account, policy, or contract with an insurance company (or
Line 2. Report on line 2 the total of all insurance fees and
similar organization), at least one Schedule A would be required
commissions directly or indirectly attributable to the contract or
to be attached to the Form 5500 filed for a pension or welfare
policy placed with or retained by the plan.
plan to provide information concerning the contract year ending
Totals. Enter on line 2 the total of all such commissions and
with or within the plan year.
fees paid to agents, brokers, and other persons listed on line 3.
Do not file Schedule A for a contract that is an Administrative
Complete a separate line 3 item (elements (a) through (e)) for
Services Only (ASO) contract, a fidelity bond or policy, or a
each person listed.
fiduciary liability insurance policy. Also, if a Schedule A for a
For purposes of lines 2 and 3, commissions and fees include
contract or policy is filed as part of a Form 5500 for a MTIA or
sales and base commissions and all other monetary and
103-12 IE that holds the contract, do not include a Schedule A
non-monetary forms of compensation where the broker’s,
for the contract or policy on the Form 5500s filed for the plans
agent’s, or other person’s eligibility for the payment or the
participating in the MTIA or 103-12 IE.
amount of the payment is based, in whole or in part, on the
Check the Schedule A box on the Form 5500 (Part II, line
value (e.g., policy amounts, premiums) of contracts or policies
10b(3)), and enter the number attached in the space provided if
(or classes thereof) placed with or retained by an ERISA plan,
one or more Schedules A are attached to the Form 5500.
including, for example, persistency and profitability bonuses.
The amount (or pro rata share of the total) of such commissions
or fees attributable to the contract or policy placed with or
Information entered on Schedule A should pertain to the
retained by the plan must be reported in line 2 and in line 3,
insurance contract or policy year ending with or within the plan
element (b) and/or (c), as appropriate.
year (for reporting purposes, a year cannot exceed 12 months).
Insurers must provide plan administrators with a
Example. If an insurance contract year begins on July 1
proportionate allocation of commissions and fees attributable to
and ends on June 30, and the plan year begins on January 1
each contract. Any reasonable method of allocating
and ends on December 31, the information on the Schedule A
commissions and fees to policies or contracts is acceptable,
attached to the 2009 Form 5500 should be for the insurance
provided the method is disclosed to the plan administrator. A
contract year ending on June 30, 2009.
reasonable allocation method could, in the Department of
Labor’s view, allocate fees and commissions to a Schedule A
Exception. If the insurance company maintains records on the
based on a calendar year calculation even if the plan year or
basis of a plan year rather than a policy or contract year, the
policy year was not a calendar year. For additional information
information entered on Schedule A may pertain to the plan year
on these Schedule A reporting requirements, see ERISA
instead of the policy or contract year.
Advisory Opinion 2005-02A, available on the Internet at
Include only the contracts issued to or held by the plan, GIA,
MTIA, or 103-12 IE for which the Form 5500 is being filed.
Where benefits under a plan are purchased from and
Lines A, B, C, and D. This information must be the same as
guaranteed by an insurance company, insurance service, or
reported in Part II of the Form 5500 to which this Schedule A is
other similar organization, and the contract or policy is reported
on a Schedule A, payments of reasonable monetary
compensation by the insurer out of its general assets to
Do not use a social security number in lieu of an EIN. The
affiliates or third parties for performing administrative activities
Schedule A and its attachments are open to public inspection,
necessary for the insurer to fulfill its contractual obligation to
and the contents are public information and are subject to
provide benefits, where there is no direct or indirect charge to
publication on the Internet. Because of privacy concerns, the
the plan for the administrative services other than the insurance
inclusion of a social security number on this Schedule A or any
premium, then the payments for administrative services by the
of its attachments may result in the rejection of the filing.
insurer to the affiliates or third parties do not need to be
You can apply for an EIN from the IRS online, by telephone,
reported on lines 2 and 3 of Schedule A. This would include
by fax, or by mail depending on how soon you need to use the
compensation for services such as recordkeeping and claims
EIN. For more information, see Section 3: Electronic Filing
processing services provided by a third party pursuant to a
Requirement under General Instructions to Form 5500. The
contract with the insurer to provide those services but would not
EBSA does not issue EINs.
include compensation provided by the insurer incidental to the
Instructions for Schedule A (Form 5500)