Fillable Schedule A (Form 5500) - Insurance Information

Schedule A (Form 5500) 1998

Page

Part III

Insured Welfare Plans

Provide information for each contract on a separate Part III. If more than one contract covers the same group of employees of the

same employer(s) or members of the same employee organization(s), the information may be combined for reporting purposes if

such contracts are experience-rated as a unit. 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.

(a) Contract or

(b) Type of

(d) Premium rate or

identification number

benefit

each contract

subscription charge

Experience-rated contracts: a Premiums: (i) Amount received

(ii)

Increase (decrease) in amount due but unpaid

(iii)

Increase (decrease) in unearned premium reserve

(iv)

Premiums earned, add (i) and (ii), and subtract (iii)

Benefit charges: (i) Claims paid

(ii)

Increase (decrease) in claim reserves

(iii)

Incurred claims (add (i) and (ii))

(iv)

Claims charged

Remainder of premium: (i) Retention charges (on an accrual basis)—

(A)

Commissions

(B)

Administrative service or other fees

(C)

Other specific acquisition costs

(D)

Other expenses

(E)

Taxes

(F)

Charges for risks or contingencies

(G)

Other retention charges

(H)

Total retention

(ii)

Dividends or retroactive rate refunds. (These amounts were

paid in cash, or

credited.)

d Status of policyholder reserves at end of year: (i) Amount held to provide benefits after retirement

(ii)

Claim reserves

(iii)

Other reserves

e Dividends or retroactive rate refunds due. (Do not include amount entered in c(ii).)

Nonexperience-rated contracts: a Total premiums or subscription charges paid to carrier

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, report amount

Specify nature of costs

If more space is required for any item, attach additional sheets the same size as this form.

General Instructions

Plans participating in master trust(s) and 103-12

Note: For purposes of this item, commissions and

IEs.—See Investment Arrangements Filing

fees include amounts paid by an insurance company

This schedule must be attached to Form 5500 or

Directly With DOL on page 4 of the instructions for

on the basis of the aggregate value (e.g., policy

5500-C/R for every defined benefit, defined

Form 5500 or 5500-C/R.

amounts, premiums) of contracts or

contribution, and welfare benefit plan where any

policies (or classes thereof) placed or retained. The

Line 2(c).—Since the plan coverage may fluctuate

benefits under the plan are provided by an

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

during the year, the administrator should estimate

insurance company, insurance service, or other

commissions or fees attributable to the contract or

the number of persons that were covered by the

similar organization.

policy placed with or retained by the plan must be

plan at the end of the policy or contract year.

reported in column (c) or (d), as appropriate.

Specific Instructions

Where contracts covering individual employees

Fees paid by insurance carriers to persons other

are grouped, entries should be determined as of the

than agents and brokers should be reported in Parts

Information entered on Schedule A (Form 5500)

end of the plan year.

II and III on Schedule A (Form 5500) as acquisition

should pertain to the insurance contract or policy

Lines 2(d) and (e).—Enter the beginning and ending

costs, administrative charges, etc., as appropriate.

year ending with or within the plan year (for

dates of the policy year for each contract listed

For plans with 100 or more participants, fees paid

reporting purposes, a year cannot exceed 12

under column (b). Enter “N/A” in column (d) if

by employee benefit plans to agents, brokers, and

months). For example, if an insurance contract year

separate contracts covering individual employees

other persons are to be reported on Schedule C

begins on July 1 and ends on June 30, and the plan

are grouped.

(Form 5500).

year begins on January 1 and ends on December

Line 3.—Report all sales commissions in column (c)

31, the Schedule A information attached to the 1998

Line 5a.—The rate information called for here may

regardless of the identity of the recipient. Do not

Form 5500 should be for the insurance contract

be furnished by attaching the appropriate schedules

report override commissions, salaries, bonuses, etc.,

year ending on June 30, 1998.

of current rates filed with the appropriate state

paid to a general agent or manager for managing an

insurance departments or by providing a statement

Exception: If the insurance company maintains

agency, or for performing other administrative

regarding the basis of the rates.

records on the basis of a plan year rather than a

functions.

policy or contract year, the information entered on

Line 6.—Show deposit fund amounts rather than

Fees to be reported in column (d) represent

Schedule A (Form 5500) may pertain to the plan

experience credit records when both are maintained.

payments by insurance carriers to agents and

year instead of the policy or contract year.

Line 8(d).—The rate information called for here may

brokers for items other than commissions (e.g.,

Include only the contracts issued to the plan for

be furnished by attaching the appropriate schedules

service fees, consulting fees, and finders fees).

which this return/report is being filed.

of current rates or a statement as to the basis of the

rates.

Schedule A (Form 5500) - Insurance Information - 1998 Page 2

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