Fillable Schedule A (Form 5500) - Insurance Information

SCHEDULE A

Insurance Information

OMB No. 1210-0016

(Form 5500)

1998

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

Inspection

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

Three-digit

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

Policy or contract year

Coverage:

(a) Name of insurance carrier

identification

persons covered at end of

(d) From

(e) To

number

policy or contract year

Insurance fees and commissions paid to agents and brokers:

(d) Fees paid

(a) Contract or

(b) Name and address of the agents or brokers to

commissions paid

Amount

Purpose

identification number

whom commissions or fees were paid

Total

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

(ii)

Dividends and credits

(iii)

Interest credited during the year

(iv)

Transferred from separate account

(v)

Other (specify)

(vi)

Total additions

c Total of balance and additions (add a and b(vi))

d Deductions:

(i)

Disbursed from fund to pay benefits or purchase annuities during year

(ii)

Administration charge made by carrier

(iii)

Transferred to separate account

(iv)

Other (specify)

(v)

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

Schedule A (Form 5500) - Insurance Information - 1998

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