Schedule A (Form 5500) - Insurance Information - 1998

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Insurance Information
OMB No. 1210-0016
(Form 5500)
Department of the Treasury
This schedule is required to be filed under section 104 of the
Internal Revenue Service
Employee Retirement Income Security Act of 1974.
This Form Is
Department of Labor
File as an Attachment to Form 5500 or 5500-C/R.
Open to Public
Pension and Welfare Benefits Administration
Insurance companies are required to provide this information
as per ERISA section 103(a)(2).
Pension Benefit Guaranty Corporation
For calendar year 1998 or fiscal plan year beginning
, 1998, and ending
, 19
Part I must be completed for all plans required to file this schedule.
Enter master trust or 103-12 IE name in place of “sponsor”
and specify investment account or 103-12 IE in place of
Part II must be completed for all insured pension plans.
“plan” if filing with DOL for a master trust or 103-12 IE.
Part III must be completed for all insured welfare plans.
Name of plan sponsor as shown on line 1a of Form 5500 or 5500-C/R
Employer identification number
Name of plan
plan number
Part I
Summary of All Insurance Contracts Included in Parts II and III
Group all contracts in the same manner as in Parts II and III.
Check appropriate box:
Welfare plan
Pension plan
Combination pension and welfare plan
(b) Contract or
(c) Approximate number of
Policy or contract year
(a) Name of insurance carrier
persons covered at end of
(d) From
(e) To
policy or contract year
Insurance fees and commissions paid to agents and brokers:
(d) Fees paid
(c) Amount of
(a) Contract or
(b) Name and address of the agents or brokers to
commissions paid
identification number
whom commissions or fees were paid
Premiums due and unpaid at end of the plan year
: Contract or identification number
Part II
Insured Pension Plans
Provide information for each contract on a separate Part II. Where individual contracts are provided,
the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report.
Contract or identification number
Contracts with allocated funds, (for example, individual policies or group deferred annuity contracts):
a State the basis of premium rates
b Total premiums paid to carrier
c If the carrier, service, or other organization incurred any specific costs in connection with the acquisition
or retention of the contract or policy, other than reported in 3 above, enter amount
Specify nature of costs
Contracts with unallocated funds, (for example, deposit administration or immediate participation
guarantee contracts). Do not include portions of these contracts maintained in separate accounts:
a Balance at the end of the previous policy year
b Additions: (i) Contributions deposited during year
Dividends and credits
Interest credited during the year
Transferred from separate account
Other (specify)
Total additions
c Total of balance and additions (add a and b(vi))
d Deductions:
Disbursed from fund to pay benefits or purchase annuities during year
Administration charge made by carrier
Transferred to separate account
Other (specify)
Total deductions
e Balance at end of current policy year (subtract d(v) from c)
Separate accounts: Current value of plan’s interest in separate accounts at year end
For Paperwork Reduction Act Notice, see the Instructions for Form 5500 or 5500-C/R.
Cat. No. 13505I
Schedule A (Form 5500) 1998


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