OMB No. 1545-2089
Report of Employer-Owned Life Insurance Contracts
(Rev. January 2010)
Department of the Treasury
Attach to the policyholder’s tax return—See instructions.
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 (see instructions) for each
employee included on line 2?
b If “No,” enter the number of employees included on line 2 for whom the policyholder does
not have a valid consent .
that employs the person insured under
reasonably expects to purchase with
the employer-owned life insurance
regard to the employee during the
Section references are to the Internal
contract and (b) the direct or indirect
course of the employee's tenure.
Revenue Code unless otherwise noted.
beneficiary of the employer-owned life
Additional notice and consent are
Purpose of Form
required if the aggregate face amount of
the employer-owned life insurance
Related person. A related person is
Use Form 8925 to report the number of
contracts with regard to an employee
considered a policyholder if that person
employees covered by employer-owned
exceeds the amount of which the
is (a) related to the policyholder (defined
life insurance contracts issued after
employee was given notice and to which
earlier) under sections 267(b) or 707(b)
August 17, 2006, and the total amount of
the employee consented. See Q&A-9
(1), or (b) engaged in a trade or business
employer-owned life insurance in force
and Q&A-12 in Notice 2009-48.
under common control with the
on those employees at the end of the tax
policyholder. See sections 52(a) and (b).
2. Provide written notification to the
year. Policyholders must also indicate
employee that the policyholder will be a
Employee. Employee includes an
whether a valid consent has been
beneficiary of any proceeds payable
officer, director, or highly compensated
received from each covered employee,
upon the death of the employee.
employee under section 414(q).
and the number of covered employees
3. Receive written consent from the
for which a valid consent has not been
Insured. An individual must be a U.S.
employee. See Valid consent under the
citizen or resident to be considered
instructions for line 4a.
insured under an employer-owned life
See sections 101(j) and 6039I, and
insurance contract. Both individuals
Electronic notification and consent.
Notice 2009-48, 2009-24 I.R.B. 1085, for
covered by a contract covering the joint
The written notification and consent
lives of two individuals are considered
requirement can be met electronically
only if the system for electronic
Employer-owned life insurance
notification and consent meets
Notice and consent requirements. To
contract. For purposes of Form 8925,
requirements 1 through 3, above. See
qualify as an employer-owned life
an insurance contract is an employer-
Q&A-11 in Notice 2009-48 for more
insurance contract, the policyholder
owned life insurance contract if it is
must meet the notice and consent
owned by a policyholder as defined
Issue date of contract. Generally, the
requirements listed below before the
below, and covers the life of the
issue date of a life insurance contract is
issuance of the contract.
policyholder’s employee(s) on the date
the date on the policy assigned by the
1. Provide written notification to the
the life insurance contract is issued. If
insurance company on or after the date
employee stating the policyholder
you have master contracts, see section
of application. For purposes of meeting
intends to insure the employee’s life and
101(j)(3) for additional information.
the notice and consent requirements, the
the maximum face amount for which the
Policyholder. For purposes of Form
issue date of the employer-owned life
employee could be insured at the time
8925 and these instructions, a
insurance contract is the later of (1) the
the contract was issued.
policyholder is an "applicable
date of application of coverage, (2) the
The written notification must include
policyholder" as defined in section
effective date of coverage, or (3) the
a disclosure of the face amount of life
101(j)(3)(B). Generally, a policyholder is
formal issuance of the contract. See
insurance, either in dollars or as a
the person who owns the employer-
Q&A-4 in Notice 2009-48 for more
multiple of salary, that the policyholder
owned life insurance contract, and who
is (a) engaged in a trade or business
For Paperwork Reduction Act Notice, see page 2.
Cat. No. 37737A