Form 5500 Schedule A PDF Details

In the landscape of employee benefit plan reporting, the 5500 Schedule A form plays a pivotal role by providing detailed insurance information as mandated under section 104 of the Employee Retirement Income Security Act of 1974 (ERISA). Open to public inspection, this schedule requires filing as an attachment to the main Form 5500 or 5500-C/R, serving as a critical instrument for the Department of Labor, the Pension and Welfare Benefits Administration, and the Pension Benefit Guaranty Corporation. It demands comprehensive disclosure from insurance companies regarding welfare and pension plans, stipulating that insurance companies must submit specific details about premiums, fees, commissions, and the number of individuals covered under various plans within a given policy year. Navigating through the form reveals structured sections dedicated to insured pension and welfare plans, each demanding meticulous documentation of contractual specifics, premium payments, and any relevant financial transactions concerning the insurance policies held by employee benefit plans. The form not only serves to ensure transparency in the funding and management of employee benefits but also aids regulatory bodies in monitoring the compliance of these benefits with federal standards, emphasizing the need for careful adherence to reporting requirements.

QuestionAnswer
Form NameForm 5500 Schedule A
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesf5500sa form 5500 schedule a

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SCHEDULE A

 

Insurance Information

OMB No. 1210-0016

 

(Form 5500)

This schedule is required to be filed under section 104 of the

199 8

 

Department of the Treasury

 

Internal Revenue Service

Employee Retirement Income Security Act of 1974.

 

This Form Is

 

 

 

 

▶ File as an Attachment to Form 5500 or 5500-C/R.

 

Department of Labor

 

Pension and Welfare Benefits Administration

▶ Insurance companies are required to provide this information

Open to Public

 

 

 

 

 

Pension Benefit Guaranty Corporation

 

as per ERISA section 103(a)(2).

Inspection

 

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.

▶Part II must be completed for all insured pension plans.

▶Part III must be completed for all insured welfare plans.

▶Enter master trust or 103-12 IE name in place of “sponsor” and specify investment account or 103-12 IE in place of “plan” if filing with DOL for a master trust or 103-12 IE.

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.

 

 

 

 

 

1

Check appropriate box: a

Welfare plan

b

Pension plan

c

Combination pension and welfare plan

2

Coverage:

 

 

 

(b) Contract or

(c) Approximate number of

Policy or contract year

(a) Name of insurance carrier

 

identification

persons covered at end of

 

 

 

 

 

 

 

(d) From

 

(e) To

 

 

 

 

 

 

number

policy or contract year

 

 

 

 

 

 

 

 

 

 

3

Insurance fees and commissions paid to agents and brokers:

(c) Amount of

 

 

 

(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

4 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 ▶

5Contracts 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

cIf 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 ▶

6Contracts with unallocated funds, (for example, deposit administration or immediate participation guarantee contracts). Do not include portions of these contracts maintained in separate accounts:

aBalance at the end of the previous policy year

bAdditions: (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

cTotal 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

eBalance at end of current policy year (subtract d(v) from c)

7 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) 1998

 

 

Page 2

 

 

 

 

 

 

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.

 

8

(a) Contract or

 

(b) Type of

(c) List gross premium for

(d) Premium rate or

identification number

 

benefit

each contract

subscription charge

 

 

 

 

 

 

 

 

 

 

 

 

9Experience-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)

bBenefit charges: (i) Claims paid

(ii)Increase (decrease) in claim reserves

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

(iv)Claims charged

cRemainder 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.)

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

(ii)Claim reserves

(iii)Other reserves

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

10Nonexperience-rated contracts: a Total premiums or subscription charges paid to carrier

bIf 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

This schedule must be attached to Form 5500 or 5500-C/R for every defined benefit, defined contribution, and welfare benefit plan where any benefits under the plan are provided by an insurance company, insurance service, or other similar organization.

Specific Instructions

Information entered on Schedule A (Form 5500) should pertain to the insurance contract or policy year ending with or within the plan year (for reporting purposes, a year cannot exceed 12 months). For example, if an insurance contract year begins on July 1 and ends on June 30, and the plan year begins on January 1 and ends on December 31, the Schedule A information attached to the 1998 Form 5500 should be for the insurance contract year ending on June 30, 1998.

Exception: If the insurance company maintains records on the basis of a plan year rather than a policy or contract year, the information entered on Schedule A (Form 5500) may pertain to the plan year instead of the policy or contract year.

Include only the contracts issued to the plan for which this return/report is being filed.

Plans participating in master trust(s) and 103-12 IEs.—See Investment Arrangements Filing Directly With DOL on page 4 of the instructions for Form 5500 or 5500-C/R.

Line 2(c).—Since the plan coverage may fluctuate during the year, the administrator should estimate the number of persons that were covered by the plan at the end of the policy or contract year.

Where contracts covering individual employees are grouped, entries should be determined as of the end of the plan year.

Lines 2(d) and (e).—Enter the beginning and ending dates of the policy year for each contract listed under column (b). Enter “N/A” in column (d) if separate contracts covering individual employees are grouped.

Line 3.—Report all sales commissions in column (c) regardless of the identity of the recipient. Do not report override commissions, salaries, bonuses, etc., paid to a general agent or manager for managing an agency, or for performing other administrative functions.

Fees to be reported in column (d) represent payments by insurance carriers to agents and brokers for items other than commissions (e.g., service fees, consulting fees, and finders fees).

Note: For purposes of this item, commissions and fees include amounts paid by an insurance company on the basis of the aggregate value (e.g., policy amounts, premiums) of contracts or

policies (or classes thereof) placed or retained. The amount (or pro rata share of the total) of such commissions or fees attributable to the contract or policy placed with or retained by the plan must be reported in column (c) or (d), as appropriate.

Fees paid by insurance carriers to persons other than agents and brokers should be reported in Parts

IIand III on Schedule A (Form 5500) as acquisition costs, administrative charges, etc., as appropriate. For plans with 100 or more participants, fees paid by employee benefit plans to agents, brokers, and other persons are to be reported on Schedule C (Form 5500).

Line 5a.—The rate information called for here may be furnished by attaching the appropriate schedules of current rates filed with the appropriate state insurance departments or by providing a statement regarding the basis of the rates.

Line 6.—Show deposit fund amounts rather than experience credit records when both are maintained.

Line 8(d).—The rate information called for here may be furnished by attaching the appropriate schedules of current rates or a statement as to the basis of the rates.

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1. To get started, when filling in the Form 5500 Schedule A, beging with the area with the subsequent fields:

Form 5500 Schedule A conclusion process explained (portion 1)

2. Once your current task is complete, take the next step – fill out all of these fields - Part II, Insured Pension Plans Provide, Contract or identification number, Contracts with allocated funds, a State the basis of premium rates, or retention of the contract or, Contracts with unallocated funds, guarantee contracts Do not include, a Balance at the end of the, ii iii iv v vi, Dividends and credits Interest, c Total of balance and additions, i ii iii iv v, Disbursed from fund to pay, and e Balance at end of current policy with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Filling out section 2 in Form 5500 Schedule A

Always be extremely mindful while filling in guarantee contracts Do not include and a State the basis of premium rates, as this is the section where many people make a few mistakes.

3. In this particular step, examine a Contract or, identification number, b Type of, benefit, c List gross premium for, each contract, d Premium rate or subscription, Increase decrease in amount due, Experiencerated contracts a, Increase decrease in claim, Commissions Administrative service, A B C D E F G H Dividends or, paid in cash or, credited, and d Status of policyholder reserves. All of these should be filled out with utmost accuracy.

Part # 3 for submitting Form 5500 Schedule A

4. It's time to complete this next part! Here you will get all these ii iii, Claim reserves Other reserves, e Dividends or retroactive rate, Nonexperiencerated contracts a, If the carrier service or other, If more space is required for any, General Instructions This schedule, Plans participating in master, Where contracts covering, are grouped entries should be, Note For purposes of this item, Fees paid by insurance carriers to, and than agents and brokers should be blanks to complete.

How to fill out Form 5500 Schedule A part 4

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