Professional Documents
Culture Documents
2005
Department of the Treasury This schedule is required to be filed under section 104 of the
Internal Revenue Service Employee Retirement Income Security Act of 1974.
Department of Labor
▼
File as an attachment to Form 5500.
Employee Benefits Security
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▼
Administration Insurance companies are required to provide this information This Form is Open to
Pension Benefit Guaranty Corporation pursuant to ERISA section 103(a)(2). Public Inspection.
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For calendar plan year 2005
or fiscal plan year beginning MM / D D / Y Y Y Y and ending MM / D D / Y Y Y Y
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A Name of plan
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B Three-digit
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plan number
C Plan sponsor's name as shown on line 2a of Form 5500 D Employer Identification Number
E
US
Part I Information Concerning Insurance Contract Coverage, Fees, and Commissions
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NO
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.
1 Coverage:
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(a) Name of insurance carrier
,D
LY
ON
ES
2 Insurance fees and commissions paid to agents, brokers and other persons. Enter the total fees and total commissions
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below and list agents, brokers and other persons individually in descending order of the amount paid in the items on
the following page(s) in Part I.
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▲ ▲ ▲ .00 ▲ ▲ ▲ .00
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For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 13505I Schedule A (Form 5500) 2005
0 5 0 5 A A 0 1 0 V
v8.2
Schedule A (Form 5500) 2005 Page 2
Official Use Only
(a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid
Name
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Street Address
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(b) Amount of commissions paid (c) Fees paid / Amount (e) Organization
code
▲ ▲ ▲ .00 ▲ ▲ ▲ .00
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FO
(d) Fees paid / Purpose
E
US
T
NO
(a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid
Name
O
Street Address ,D
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City State Zip Code
ON
(b) Amount of commissions paid (c) Fees paid / Amount (e) Organization
code
▲ ▲ ▲ .00 ▲ ▲ ▲ .00
ES
(a) Name and address of the agents, brokers or other persons to whom commissions or fees were paid
N
Name
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AT
Street Address
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code
▲ ▲ ▲ .00 ▲ ▲ ▲ .00
IN
0 5 0 5 A A 0 2 0 W
Schedule A (Form 5500) 2005 Page 3
Official Use Only
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3 Current value of plan's interest under this contract in the general account at year end ▲ ▲ ▲ .00
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FI
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▲ ▲ ▲ .00
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4 Current value of plan's interest under this contract in separate accounts at year end
E
5 Contracts With Allocated Funds
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a State the basis of premium rates
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NO
▼
O
b Premiums paid to carrier ............................................................................................... ▲ ▲ ▲ .00
,D
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c Premiums due but unpaid at the end of the year ........................................................
▲ ▲ ▲ .00
ON
PU
RM
FO
f If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here .....
IN
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FO
0 5 0 5 A A 0 3 0 X
Schedule A (Form 5500) 2005 Page 4
Official Use Only
6 Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)
a Type of contract
(1) deposit administration (2) immediate participation guarantee (3) guaranteed investment
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(4) other (specify below)
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▼
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b Balance at the end of the previous year ..................................................................... ▲ ▲ ▲ .00
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c Additions:
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(1) Contributions deposited during the year ......... ▲ ▲ ▲ .00
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(2) Dividends and credits ...................................... ▲ ▲ ▲ .00
NO
(3) Interest credited during the year ..................... ▲ ▲ ▲ .00
O
(4) Transferred from separate account ................. ▲ ▲ ▲ .00
,D
(5) Other (specify below) ....................................... ▲ ▲ ▲ .00
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ON
▼
ES
IN
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f Balance at the end of the current year (subtract e(5) from d) ................................... ▲ ▲ ▲ .00
0 5 0 5 A A 0 4 0 Y
Schedule A (Form 5500) 2005 Page 5
Official Use Only
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unit for purposes of this report.
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7 Benefit and contract type (check all applicable boxes)
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(a) Health (other than (b) Dental (c) Vision (d) Life Insurance
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dental or vision)
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(e) 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
E
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(m) Other (specify below)
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NO
▼
O
8 Experience-rated contracts
a Premiums:
,D
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(1) Amount received .............................................. ▲ ▲ ▲ .00
ON
b Benefit charges:
▲ ▲ ▲ .00
N
.00
IN
0 5 0 5 A A 0 5 0 Z
Schedule A (Form 5500) 2005 Page 6
Official Use Only
8 c Remainder of premium:
(1) Retention charges (on an accrual basis) --
(A) Commissions ............................................ ▲ ▲ ▲ .00
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(B) Administrative service or other fees ........ ▲ ▲ ▲ .00
▲ ▲ ▲ .00
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(C) Other specific acquisition costs ...............
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(D) Other expenses ........................................ ▲ ▲ ▲ .00
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▲ ▲ ▲ .00
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(E) Taxes ........................................................
E
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(G) Other retention charges ........................... ▲ ▲ ▲ .00
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NO
(H) Total retention .............................................................................................. ▲ ▲ ▲ .00
(2) Dividends or retroactive rate refunds.
O
(These amounts were 1) paid in cash, or 2) credited.) ... ▲ ▲ ▲ .00
d Status of policyholder reserves at end of year:
,D
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(1) Amount held to provide benefits after retirement ............................................... ▲ ▲ ▲ .00
ON
9 Nonexperience-rated contracts:
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0 5 0 5 A A 0 6 0 -