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1 Attention! This form or schedule is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The Form 5500 series of forms and schedules is printed on special paper with green drop-out ink so it can be processed by the new computerized processing system EFAST. The Forms 5500 and 5500-EZ (and related schedules) are included in the appropriate packages that were mailed to all filers of record. These forms and schedules may also be obtained by calling TAX-FORM ( ). Be sure to order using the IRS form number. Check the Department of Labor s Web Site at for additional information concerning the new processing system, electronic filing, software, and non-standard filings.
2 SCHEDULE A (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Pension and Welfare Benefits Administration Pension Benefit Guaranty Corporation For the calendar year 1999 or fiscal plan year beginning A Name of plan Part I Insurance Information This schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974 File as an attachment to Form Insurance companies are required to provide this information pursuant to ERISA section 103(a)(2)., and ending OMB No This Form is Open to Public Inspection. Information Concerning Insurance Contract Coverage, Fees, and Commissions Provide information for each contract on a separate Schedule A. Individual contracts grouped as a unit in Parts II and III can be reported on a single Schedule A. B Three-digit plan number C Plan sponsor's name as shown on line 2a of Form 5500 D Employer Identification Number (a) 1 Coverage: Name of insurance carrier (b) EIN (c) NAIC code Contract or identification number Approximate number of persons covered at end of policy or contract year. Policy or contract year (f) From MM/ DD / YYYY (g) To 2 Insurance fees and commissions paid to agents, brokers, and other persons: Totals Amount of commissions paid MM/ DD / YYYY P Fees paid / Amount MM/ DD / YYYY MM/ DD / YYYY For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form Cat. No I Schedule A (Form 5500) 1999
3 (a) (a) Schedule A (Form 5500) 1999 Page 2 Name and address of the agents, brokers or other persons to whom commissions or fees were paid (b) Amount of commissions paid (c) Fees paid / Amount (a) Fees paid / Purpose Name and address of the agents, brokers or other persons to whom commissions or fees were paid (b) Amount of commissions paid (c) Fees paid / Amount Name and address of the agents, brokers or other persons to whom commissions or fees were paid Name Street Address City State Zip Code (b) Amount of commissions paid (c) Fees paid / Amount Fees paid / Purpose Name Street Address Fees paid / Purpose Q City State Zip Code Name Street Address City State Zip Code Organization code Organization code Organization code
4 Part II e Type of contract (1) individual policies (2) group deferred annuity f Schedule A (Form 5500) 1999 Page 3 (3) other (specify below) If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here Investment and Annuity Contract Information 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. 3 Current value of plan's interest under this contract in the general account at year end 4 Current value of plan's interest under this contract in separate accounts at year end 5 Contracts With Allocated Funds a State the basis of premium rates b Premiums paid to carrier... c Premiums due but unpaid at the end of the year... d If the carrier, service, or other organization incurred any specific costs in connection with the acquisition or retention of the contract or policy, enter amount... Specify nature of costs R
5 Schedule A (Form 5500) 1999 Page 4 6 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts) a Type of contract (5) Total deductions... f Balance at the end of the current year (subtract e(5) from d)... (1) deposit administration (2) immediate participation guarantee (3) guaranteed investment (4) other (specify below) b Balance at the end of the previous year... c Additions: (1) Contributions deposited during the year... (2) Dividends and credits... (3) Interest credited during the year... (4) Transferred from separate account... (5) Other (specify below)... (6) Total additions... d Total of balance and additions (add b and c(6))... e Deductions: (1) Disbursed from fund to pay benefits or purchase annuities during year... (2) Administration charge made by carrier... (3) Transferred to separate account... (4) Other (specify below) S
6 Part III Schedule A (Form 5500) 1999 Page 5 7 Benefit and contract type (check all applicable boxes) (a) Health (other than (b) Dental (c) Vision Life Insurance dental or vision) Temporary disability (f) Long-term disability (g) Supplemental (h) Prescription drug (accident and sickness) unemployment (i) Stop loss (large deductible) (j) HMO contract (k) PPO contract (l) Indemnity contract (m) Other (specify below) 8 Experience-rated contracts a Premiums: (1) Amount received... (2) Increase (decrease) in amount due but unpaid... (3) Increase (decrease) in unearned premium reserve... (4) Earned ((1) + (2) - (3))... b Benefit charges: Welfare Benefit Contract Information 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. (1) Claims paid... (2) Increase (decrease) in claim reserves... (3) Incurred claims (add (1) and (2))... (4) Claims charged T
7 c Remainder of premium: (1) 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) Schedule A (Form 5500) 1999 Page 6 Charges for risks or other contingencies (G) Other retention charges... (H) Total retention... (2) Dividends or retroactive rate refunds. (These amounts were 1) paid in cash, or 2) credited.)... d Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement... (2) Claim reserves... (3) Other reserves... e Dividends or retroactive rate refunds due. (Do not include amount entered in c(2).)... 9 Nonexperience-rated contracts: a Total premiums or subscription charges paid to carrier... b 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 Part I, item 2 above, report amount... Specify nature of costs below U
2006 This Form is Open to Public Inspection.
SCHEDULE A (Form 5500) Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Insurance Information This
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Annual Return/Report of Employee Benefit
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee
Annual Return/Report of Employee Benefit Plan
Form 55 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee Benefit
Annual Return/Report of Employee Benefit Plan
Form 55 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee Benefit
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Annual Return/Report of Employee Benefit
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Annual Return/Report of Employee Benefit
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Annual Return/Report of Employee Benefit
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Annual Return/Report of Employee Benefit
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee Benefit
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee Benefit
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee
2005 This Form is NOT Open to Public Inspection.
Attention: Telephone requests for the 2005 Form 5500-series forms, schedules and instructions will not be filled until December 1, 2005. Requests for the 2005 Form 5500-series products can be made on the
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Annual Return/Report of Employee Benefit
Note: You can also use the Internet link Forms and Publications by U.S. Mail to request a limited number of these forms and schedules.
This form is referenced in an endnote at the Bradford Tax Institute. CLICK HERE to go to the home page. Attention: Telephone requests for the forms, schedules, and instructions for the 2008 Form 5500-series
Annual Return/Report of Employee Benefit Plan
Form 5500 Department of the Treasury Internal Revenue Service Department of Labor Employee Benefits Security Administration Pension Benefit Guaranty Corporation Part I Annual Return/Report of Employee
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Attention! This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is a "machine
Attention! The form or publcations above may be obtained by calling ). Be sure to order using the IRS form or publication number.
Attention! This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is a "machine
Do Not Cut or Separate Forms on This Page Do Not Cut or Separate Forms on This Page
Attention! This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is a "machine
Additional information about the printing of these specialized tax forms can be found in IRS Publications 1141, 1167, 1179, and other IRS resources.
Attention: This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is designed as
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Additional information about the printing of these specialized tax forms can be found in IRS Publications 1141, 1167, 1179, and other IRS resources.
Attention: This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is designed as
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Attention! This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is a "machine
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Attention! This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is a "machine
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Additional information about the printing of these specialized tax forms can be found in IRS Publications 1141, 1167, 1179, and other IRS resources.
Attention: This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is designed as
Additional information about the printing of these specialized tax forms can be found in IRS Publications 1141, 1167, 1179, and other IRS resources.
Attention: This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is designed as
Additional information about the printing of these specialized tax forms can be found in IRS Publications 1141, 1167, 1179, and other IRS resources.
Attention: This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is designed as
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Additional information about the printing of these specialized tax forms can be found in IRS Publications 1141, 1167, 1179, and other IRS resources.
Attention: This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is designed as
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Additional information about the printing of these specialized tax forms can be found in IRS Publications 1141, 1167, 1179, and other IRS resources.
Attention: This form is provided for informational purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The printed version of this form is designed as