Form 5500 Schedule A Instructions - Insurance Information

Lines A, B, C, and D. This information should be the same as

2004 Instructions for Schedule A

reported in Part II of the Form 5500 to which this Schedule A is

attached. You may abbreviate the plan name (if necessary) to

(Form 5500)

fit in the space provided.

Insurance Information

Do not use a social security number in lieu of an EIN. The

Schedule A and its attachments are open to public inspection,

and the contents are public information and are subject to

General Instructions

publication on the Internet. Because of privacy concerns, the

inclusion of a social security number on this Schedule A or any

Who Must File

of its attachments may result in the rejection of the filing.

Schedule A, Insurance Information, must be attached to the

EINs may be obtained by applying for one on Form SS-4,

Form 5500 filed for every defined benefit pension plan, defined

Application for Employer Identification Number, as soon as

contribution pension plan, and welfare benefit plan if any

possible. You can obtain Form SS-4 by calling

benefits under the plan are provided by an insurance company,

1-800-TAX-FORM (1-800-829-3676) or at the IRS Web Site at

insurance service, or other similar organization (such as Blue

The EBSA does not issue EINs.

Cross, Blue Shield, or a health maintenance organization). This

Part I - Information Concerning Insurance Contract

includes investments with insurance companies such as

Coverage, Fees, and Commissions

guaranteed investment contracts (GICs).

For example, if Form 5500 line 9a(1), 9a(2), 9b(1), or 9b(2)

Line 1(c). Enter the code number assigned by the National

is checked, indicating that either the plan funding arrangement

Association of Insurance Commissioners (NAIC) to the

or plan benefit arrangement includes an account, policy, or

insurance company. If none has been assigned, enter zeros

contract with an insurance company (or similar organization), at

(-0-) in the spaces provided.

least one Schedule A (Form 5500) would be required to be

Line 1(d). If individual policies with the same carrier are

attached to the Form 5500 filed for a pension or welfare plan to

grouped as a unit for purposes of this report, and the group

provide information concerning the contract year ending with or

does not have one identification number, you may use the

within the plan year.

contract or identification number of one of the individual

contracts provided this number is used consistently to report

In addition, Schedules A must be attached to a Form 5500

these contracts as a group and the plan administrator maintains

filed for GIAs, MTIAs, and 103-12 IEs for each insurance or

the records necessary to disclose all the individual contract

annuity contract held in the MTIA, or 103-12 IE or by the GIA.

numbers in the group upon request. Use separate Schedules A

See the Form 5500 instructions for specific requirements for

to report individual contracts that cannot be grouped as a unit.

GIAs, MTIAs, and 103-12 IEs.

Line 1(e). Since plan coverage may fluctuate during the year,

Do not file Schedule A if: (1) the contract is an Administrative

the administrator should estimate the number of persons that

Services Only (ASO) contract; (2) the Form 5500 is being filed

were covered by the contract at the end of the policy or contract

for a plan participating in a MTIA or 103-12 IE for which a Form

year. Where contracts covering individual employees are

5500 is being filed that reports the contract on a Schedule A

grouped, compute entries as of the end of the plan year.

filed with the MTIA or 103-12 IE Form 5500; or (3) the Form

5500 is being filed for a plan that covers only: (A) an individual

Lines 1(f) and (g). Enter the beginning and ending dates of the

or an individual and his or her spouse who wholly own a trade

policy year for the contract identified in 1(d). Enter ‘‘N/A’’ in 1(f)

or business, whether incorporated or unincorporated; or

if separate contracts covering individual employees are

(B) partners, or partners and one or more of the partners’

grouped.

spouses in a partnership.

Line 2. List all persons in descending order by the amount of

Check the Schedule A box on the Form 5500 (Part II, line

commissions and fees paid. Additional pages may be

10b(3)), and enter the number attached in the space provided if

necessary. You can get additional hand print pages by calling

one or more Schedules A are attached to the Form 5500.

1-800-TAX-FORM (1-800-829-3676) and requesting additional

schedules.

Important Reminder. The insurance company (or similar

organization) is required to provide the plan administrator with

Totals. Enter the total of all commissions and fees paid to

the information needed to complete the return/report, pursuant

persons listed on line 2.

to ERISA section 103(a)(2). If you do not receive this

Complete a separate item (elements (a) through (e)) for

information in a timely manner, contact the insurance company

each person. Enter the name and address of the person

(or similar organization). If information is missing on Schedule A

identified in element (a) and complete elements (b) through (e)

(Form 5500) due to a refusal to provide information, note this on

for each person as specified below.

the Schedule A.

Element (b). Report all sales commissions regardless of the

Specific Instructions

identity of the recipient. Do not report override commissions,

salaries, bonuses, etc., paid to a general agent or manager for

Information entered on Schedule A (Form 5500) should pertain

managing an agency, or for performing other administrative

to the insurance contract or policy year ending with or within the

functions.

plan year (for reporting purposes, a year cannot exceed 12

months).

Element (c). Fees to be reported represent payments by

insurance carriers to agents, brokers and other persons for

Example. If an insurance contract year begins on July 1 and

items other than commissions (e.g., service fees, consulting

ends on June 30, and the plan year begins on January 1, and

fees, and finders fees). Fees paid by insurance carriers to

ends on December 31, the information on the Schedule A

persons other than agents and brokers should be reported

attached to the 2004 Form 5500 should be for the insurance

here, not in Parts II and III on Schedule A as acquisition costs,

contract year ending on June 30, 2004.

administrative charges, etc. For plans, GIAs, MTIAs and 103-12

Exception. If the insurance company maintains records on the

IEs required to file Part I of Schedule C, fees paid by employee

basis of a plan year rather than a policy or contract year, the

benefit plans or these DFEs to agents, brokers, and other

information entered on Schedule A (Form 5500) may pertain to

persons are also to be reported on Schedule C (Form 5500),

the plan year instead of the policy or contract year.

unless the only compensation in relation to the plan or DFE

Include only the contracts issued to or held by the plan, GIA,

consists of insurance fees and commissions listed on the

MTIA or 103-12 IE for which the Form 5500 is being filed.

Schedule A.

-21-

Instructions for Schedule A (Form 5500)

Form 5500 Schedule A Instructions - Insurance Information - 2004

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