Form 5500 Schedule A Instructions - Insurance Information - 2004


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’
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
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
plan year (for reporting purposes, a year cannot exceed 12
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.
Instructions for Schedule A (Form 5500)


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