Report of Employer-Owned Life Insurance Contracts
OMB No. 1545-2089
(Rev. September 2017)
Attach to the policyholder’s tax return. See instructions.
Department of the Treasury
Go to for the latest information.
Internal Revenue Service
Name(s) shown on return
Name of policyholder, if different from above
Identifying number, if different from above
Type of business
Enter the number of employees the policyholder had at the end of the tax year .
Enter the number of employees included on line 1 who were insured at the end of the tax
year under the policyholder’s employer-owned life insurance contract(s) issued after August
17, 2006. See Section 1035 exchanges on page 2 for an exception .
Enter the total amount of employer-owned life insurance in force at the end of the tax year
for employees who were insured under the contract(s) specified on line 2 .
4 a Does the policyholder have a valid consent for each employee included on
line 2? See instructions
b If “No,” enter the number of employees included on line 2 for whom the policyholder does
not have a valid consent .
Section references are to the Internal
Policyholder. For purposes of Form
The written notification must include a
Revenue Code unless otherwise noted.
8925 and these instructions, a
disclosure of the face amount of life
policyholder is an “applicable
insurance, either in dollars or as a
policyholder” as defined in section
multiple of salary, that the policyholder
For the latest information about
101(j)(3)(B). Generally, a policyholder is
reasonably expects to purchase with
developments related to Form 8925 and
the person who owns the employer-
regard to the employee during the
its instructions, such as legislation
owned life insurance contract, and who
course of the employee’s tenure.
enacted after they were published, go to
is (a) engaged in a trade or business that
Additional notice and consent are
required if the aggregate face amount of
employs the person insured under the
employer-owned life insurance contract
the employer-owned life insurance
and (b) the direct or indirect beneficiary
contracts with regard to an employee
of the employer-owned life insurance
exceeds the amount of which the
Purpose of Form
employee was given notice and to which
Use Form 8925 to report the number of
the employee consented. See Q&A-9
Related person. A related person is
employees covered by employer-owned
and Q&A-12 in Notice 2009-48.
considered a policyholder if that person
life insurance contracts issued after
is (a) related to the policyholder (defined
2. Provide written notification to the
August 17, 2006, and the total amount of
earlier) under sections 267(b) or 707(b)
employee that the policyholder will be a
employer-owned life insurance in force
beneficiary of any proceeds payable
(1), or (b) engaged in a trade or business
on those employees at the end of the tax
under common control with the
upon the death of the employee.
year. Policyholders must also indicate
policyholder. See sections 52(a) and (b).
3. Receive written consent from the
whether a valid consent has been
Employee. Employee includes an
employee. See Valid consent under the
received from each covered employee,
officer, director, or highly compensated
instructions for line 4a.
and the number of covered employees
employee under section 414(q).
Electronic notification and consent.
for which a valid consent has not been
Insured. An individual must be a U.S.
The written notification and consent
citizen or resident to be considered
requirement can be met electronically
insured under an employer-owned life
For more information, see sections
only if the system for electronic
insurance contract. Both individuals
101(j) and 6039I, and Notice 2009-48,
notification and consent meets
covered by a contract covering the joint
2009-24 I.R.B. 1085, available at
requirements 1 through 3, above. See
lives of two individuals are considered
Q&A-11 in Notice 2009-48 for more
Notice and consent requirements. To
Issue date of contract. Generally, the
Employer-owned life insurance
qualify as an employer-owned life
issue date of a life insurance contract is
contract. For purposes of Form 8925,
insurance contract, the policyholder
the date on the policy assigned by the
an insurance contract is an employer-
must meet the notice and consent
insurance company on or after the date
owned life insurance contract if it is
requirements listed below before the
of application. For purposes of meeting
owned by a policyholder as defined
issuance of the contract.
the notice and consent requirements, the
below, and covers the life of the
issue date of the employer-owned life
1. Provide written notification to the
policyholder’s employee(s) on the date
insurance contract is the later of (1) the
employee stating the policyholder
the life insurance contract is issued. If
date of application of coverage, (2) the
intends to insure the employee’s life and
you have master contracts, see section
effective date of coverage, or (3) the
the maximum face amount for which the
101(j)(3) for additional information.
formal issuance of the contract. See
employee could be insured at the time
Q&A-4 in Notice 2009-48 for more
the contract was issued.
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 37737A