Form 5500 Schedule A Instructions - Insurance Information

For purposes of line 2, commissions and fees include

pension plan and the contract was entered into before March

amounts paid by an insurance company on the basis of

20, 1992, or (2) the Schedule A is filed for a defined contribution

the aggregate value (e.g., policy amounts, premiums) of

pension plan and the contract is a fully benefit-responsive

CAUTION

contracts or policies (or classes thereof) placed or retained. The

contract, i.e., it provides a liquidity guarantee by a financially

amount (or pro rata share of the total) of such commissions or

responsible third party of principal and previously accrued

fees attributable to the contract or policy placed with or retained

interest for liquidations, transfers, loans, or hardship

by the plan must be reported in element (b) or (c), as

withdrawals initiated by plan participants exercising their rights

appropriate.

to withdraw, borrow, or transfer funds under the terms of a

defined contribution plan that do not include substantial

Element (e). Enter the most appropriate code.

restrictions to participants’ access to plan funds.

Line 5a. The rate information called for here may be furnished

Code Type of Organization

by attaching the appropriate schedules of current rates filed

Banking, Savings & Loan Association, Credit Union or

with the appropriate state insurance department or by providing

other similar financial institution

a statement regarding the basis of the rates. Enter “see

Trust Company

attached” if appropriate.

Insurance Agent or Broker

Agent or Broker other than insurance

Lines 6a through 6f. Report contracts with unallocated funds.

Third party administrator

Do not include portions of these contracts maintained in

Investment Company/Mutual Fund

separate accounts. Show deposit fund amounts rather than

Investment Manager/Adviser

experience credit records when both are maintained.

Labor Union

Foreign entity (e.g., an agent or broker, bank, insurance

Part III - Welfare Benefit Contract Information

company, etc., not operating within the jurisdictional

boundaries of the United States)

Line 7i. Report a stop-loss insurance policy that is an asset of

Other

the plan.

Part II - Investment and Annuity Contract Information

Note. Employers sponsoring welfare plans may purchase a

Line 3. Enter the current value of the plan’s interest at year end

stop loss insurance policy with the employer as the insured to

in the contract reported on line 6, e.g., deposit administration

help the employer manage its risk associated with its liabilities

(DA), immediate participation guarantee (IPG), or guaranteed

under the plan. These employer contracts with premiums paid

investment contracts (GIC).

exclusively out of the employer’s general assets without any

employee contributions generally are not plan assets and are

Exception. Contracts reported on line 6 need not be included

not reportable on Schedule A.

on line 3 if (1) the Schedule A is filed for a defined benefit

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Instructions for Schedule A (Form 5500)

Form 5500 Schedule A Instructions - Insurance Information - 2004 Page 2

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