this Schedule A or any of its attachments may result in the
rejection of the filing.
2016 Instructions for Schedule A
You can apply for an EIN from the IRS online, by
telephone, by fax, or by mail depending on how soon you need
to use the EIN. For more information, see Section 3: Electronic
Filing Requirement under General Instructions to Form 5500.
The EBSA does not issue EINs.
Part I – Information Concerning Insurance Contract
Who Must File
Coverage, Fees, and Commissions
Schedule A (Form 5500) must be attached to the Form 5500
Line 1(c). Enter the code number assigned by the National
filed for every defined benefit pension plan, defined
Association of Insurance Commissioners (NAIC) to the
contribution pension plan, and welfare benefit plan required to
insurance company. If none has been assigned, enter zeros
file a Form 5500 if any benefits under the plan are provided by
“0” in the spaces provided.
an insurance company, insurance service, or other similar
Line 1(d). If individual policies with the same carrier are
organization (such as Blue Cross, Blue Shield, or a health
grouped as a unit for purposes of this report, and the group
maintenance organization). This includes investment contracts
does not have one identification number, you may use the
with insurance companies such as guaranteed investment
contract or identification number of one of the individual
contracts (GICs). In addition, Schedules A must be attached to
contracts, provided this number is used consistently to report
a Form 5500 filed for GIAs, MTIAs, and 103-12 IEs for each
these contracts as a group and the plan administrator
insurance or annuity contract held in the MTIA, or 103-12 IE or
maintains the records necessary to disclose all the individual
by the GIA.
contract numbers in the group upon request. Use separate
If Form 5500 line 9a(1), 9a(2), 9b(1), or 9b(2) is
Schedules A to report individual contracts that cannot be
checked, indicating that either the plan funding
grouped as a unit.
arrangement or plan benefit arrangement includes an
Line 1(e). Since plan coverage may fluctuate during the year,
account, policy, or contract with an insurance company (or
the administrator should estimate the number of persons that
similar organization), at least one Schedule A would be
were covered by the contract at the end of the policy or contract
required to be attached to the Form 5500 filed for a pension or
year. Where contracts covering individual employees are
welfare plan to provide information concerning the contract
grouped, compute entries as of the end of the plan year.
year ending with or within the plan year.
Line 1(f) and (g). Enter the beginning and ending dates of the
Do not file Schedule A for a contract that is an Administrative
policy year for the contract identified in 1(d). Leave 1(f) blank if
Services Only (ASO) contract, a fidelity bond or policy, or a
separate contracts covering individual employees are grouped.
fiduciary liability insurance policy. Also, if a Schedule A for a
Line 2. Report on line 2 the total of all insurance fees and
contract or policy is filed as part of a Form 5500 for an MTIA or
commissions directly or indirectly attributable to the contract or
103-12 IE that holds the contract, do not include a Schedule A
policy placed with or retained by the plan.
for the contract or policy on the Form 5500s filed for the plans
participating in the MTIA or 103-12 IE.
Totals. Enter on line 2 the total of all such commissions and
Check the Schedule A box on the Form 5500 (Part II, line
fees paid to agents, brokers, and other persons listed on line 3.
10b(3)), and enter the number attached in the space provided
Complete a separate line 3 item (elements (a) through (e)) for
each person listed.
if one or more Schedules A are attached to the Form 5500.
For purposes of lines 2 and 3, commissions and fees
include sales and base commissions and all other monetary
Information entered on Schedule A should pertain to the
and non-monetary forms of compensation where the broker’s
insurance contract or policy year ending with or within the plan
agent’s, or other person’s eligibility for the payment or the
year (for reporting purposes, a year cannot exceed 12
amount of the payment is based, in whole or in part, on the
value (e.g., policy amounts, premiums) of contracts or policies
Example. If an insurance contract year begins on July 1 and
(or classes thereof) placed with or retained by an ERISA plan,
ends on June 30, and the plan year begins on January 1 and
including, for example, persistency and profitability bonuses.
ends on December 31, the information on the Schedule A
The amount (or pro rata share of the total) of such
attached to the 2016 Form 5500 should be for the insurance
commissions or fees attributable to the contract or policy
contract year ending on June 30, 2016.
placed with or retained by the plan must be reported in line 2
and in line 3, element (b) and/or (c), as appropriate.
Exception. If the insurance company maintains records on the
basis of a plan year rather than a policy or contract year, the
Insurers must provide plan administrators with a
information entered on Schedule A may pertain to the plan
proportionate allocation of commissions and fees attributable
year instead of the policy or contract year.
to each contract. Any reasonable method of allocating
commissions and fees to policies or contracts is acceptable,
Include only the contracts issued to or held by the plan,
provided the method is disclosed to the plan administrator. A
GIA, MTIA, or 103-12 IE for which the Form 5500 is being filed.
reasonable allocation method could, in the Department of
Lines A, B, C, and D. This information must be the same as
Labor’s view, allocate fees and commissions to a Schedule A
reported in Part II of the Form 5500 to which this Schedule A is
based on a calendar year calculation even if the plan year or
policy year was not a calendar year. For additional information
Do not use a social security number in lieu of an EIN. The
on these Schedule A reporting requirements, see ERISA
Schedule A and its attachments are open to public inspection,
Advisory Opinion 2005-02A, available on the Internet at
and the contents are public information and are subject to
publication on the Internet. Because of privacy concerns, the
Where benefits under a plan are purchased from and
inclusion of a social security number or any portion thereof on
guaranteed by an insurance company, insurance service, or
Instructions for Schedule A (Form 5500)