Attention

:
• Telephone requests for the 2007 Form 5500-series forms, schedules, and instructions will not be filled until October 16, 2007. • Requests for the 2007 Form 5500-series products can be made on the Internet (see below) beginning October 16, 2007. Requests made prior to that date will be filled with the 2006 version of the products. The product you are about to view is provided for information purposes and should not be reproduced on personal computer printers by individual taxpayers for filing. The Forms 5500 and 5500-EZ (and related schedules) are printed on special paper with dropout ink so they can be processed by the computerized processing system “EFAST.” These forms and schedules may be obtained by calling 1-800TAX-FORM (1-800-829-3676). Be sure to order using the IRS form number. 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. Check the Department of Labor’s website at www.efast.dol.gov for additional information concerning the processing system, electronic filing, software, and “non-standard” filings. ________________________________________________

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 schedule is required to be filed under section 104 of the Employee Retirement Income Security Act of 1974. File as an attachment to Form 5500. Insurance companies are required to provide this information pursuant to ERISA section 103(a)(2).
▼ ▼

Official Use Only

OMB No. 1210-0110

2007
This Form is Open to Public Inspection.
▼ FI LI N

For calendar plan year 2007 or fiscal plan year beginning
A Name of plan

MM / D D / Y Y Y Y

and ending
B

MM / D D / Y Y Y Y
Three-digit plan number

C

Plan sponsor's name as shown on line 2a of Form 5500

D

Employer Identification Number

Part I

Information Concerning Insurance Contract Coverage, Fees, and Commissions

1 Coverage:
(a) Name of insurance carrier

A

L

P

(d) Contract or identification number

U R

P

O

(b) EIN

S E

S

O N

(c) NAIC code

LY

,D

(e)

Approximate number of persons covered at end of policy or contract year

T

IO

O

N

N

O

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.

T


(g) To

Policy or contract year

2

Totals

IN FO

Insurance fees and commissions paid to agents, brokers and other persons. Enter the total fees and total commissions 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.
Total amount of commissions paid Total fees paid / amount

FO

R

R

M

A

(f) From

MM / D D / Y Y Y Y

U

S E

MM / D D / Y Y Y Y

FO

R

G

.00

.00

For Paperwork Reduction Act Notice and OMB Control Numbers, see the instructions for Form 5500. Cat. No. 13505I Schedule A (Form 5500) 2007

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0

1

0

D
v10.1

Schedule A (Form 5500) 2007 (a)

Page

2
Official Use Only

Name and address of the agents, brokers or other persons to whom commissions or fees were paid

Name Street Address City
(b) Amount of commissions paid (c) Fees paid / Amount

State

Zip Code


(d) Fees paid / Purpose

.00

Name Street Address

(b) Amount of commissions paid

(c)

Fees paid / Amount

O N

City

LY

,D

O

N

O

(a)

Name and address of the agents, brokers or other persons to whom commissions or fees were paid

State

T

U

S E

Zip Code
(e) Organization code

(d) Fees paid / Purpose

(a)

Name and address of the agents, brokers or other persons to whom commissions or fees were paid

Street Address City

IN FO

R

M

A

T

Name

IO

N

A

L

P

U R

P

O

S E

.00

S

FO

State
(c) Fees paid / Amount

Zip Code
(e) Organization code

(b) Amount of commissions paid

R

(d) Fees paid / Purpose

FO

.00

0

5

0

7

0

0

0

2

0

E

R
.00 .00

FI LI N
.00

(e)

G

Organization code

Schedule A (Form 5500) 2007

Page

3
Official Use Only

Part II

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

.00

FI LI N
▲ ▲ ▲ ▲

G
4 Current value of plan's interest under this contract in separate accounts at year end

.00

5

O

N

O

T

U

S E

Contracts With Allocated Funds a State the basis of premium rates

FO

R

LY

,D

b Premiums paid to carrier ..............................................................................................

▲ ▲

▲ ▲

.00 .00 .00

S E

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 .........................................................................

S

O N

c Premiums due but unpaid at the end of the year .......................................................

Specify nature of costs

e Type of contract (3)

(1)

individual policies

N

A

L

P

U R

P

O

(2)

group deferred annuity

IN FO

R

M

A

T

other (specify below)

IO

f

If contract purchased, in whole or in part, to distribute benefits from a terminating plan check here ...

FO

R

0

5

0

7

0

0

0

3

0

F

Schedule A (Form 5500) 2007 6

Page

4
Official Use Only

Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts) a Type of contract (1) (4) deposit administration other (specify below) (2) immediate participation guarantee (3) guaranteed investment

FI LI N U O T
(2) (3) (4) (5) Dividends and credits ...................................... Interest credited during the year ..................... Transferred from separate account ................. Other (specify below) .......................................

G
▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲

O

N

,D

S E

S

O N

LY

S E

c Additions: (1) Contributions deposited during the year .........

FO

.00 .00 .00 .00 .00

R

b Balance at the end of the previous year ....................................................................

.00

(6)

Total additions ......................................................................................................

U R

P

▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲

▲ ▲

▲ ▲

.00 .00

(1)

IO

N

Disbursed from fund to pay benefits or purchase annuities during year .......................

A

L

d Total of balance and additions (add b and c(6)) ........................................................ e Deductions:

P

O

▲ ▲ ▲ ▲

.00 .00 .00 .00

(3) (4)

Transferred to separate account ..................... Other (specify below) .......................................

FO

R

IN FO

R

M

A

T

(2)

Administration charge made by carrier ...........

(5)

Total deductions ...................................................................................................

▲ ▲
4 0 G

▲ ▲

▲ ▲

.00 .00

f Balance at the end of the current year (subtract e(5) from d) ..................................

0

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0

7

0

0

0

Schedule A (Form 5500) 2007

Page

5
Official Use Only

Part III

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.

7

Benefit and contract type (check all applicable boxes) (a) (e) (i) (m) Health (other than dental or vision) Temporary disability (accident and sickness) Stop loss (large deductible) Other (specify below) (b) (f) (j) Dental Long-term disability HMO contract (c) (g) (k) Vision Supplemental unemployment PPO contract (d) (h) (l)

FO
.00 .00 .00

R
Indemnity contract

S

(2)

P

(3)

P

U R

Increase (decrease) in unearned premium reserve .............................

O

S E

Increase (decrease) in amount due but unpaid ...............................

O N

a Premiums: (1) Amount received ..............................................

▲ ▲ ▲

LY

,D

8

Experience-rated contracts

▲ ▲ ▲

O

N

O

T

▲ ▲ ▲ ▲

U

S E

FI LI N
▲ ▲ ▲ ▲ ▲ ▲

Life Insurance Prescription drug

G IO
b Benefit charges: (1) Claims paid ......................................................

N

A

L

(4)

Earned ((1) + (2) - (3)) ........................................................................................

.00

▲ ▲

▲ ▲

▲ ▲ ▲ ▲

.00 .00 .00 .00

(3)

Incurred claims (add (1) and (2)) ........................................................................

(4)

FO

Claims charged ....................................................................................................

R

IN FO

R

(2)

Increase (decrease) in claim reserves ...........

M

A
0

T
5

0

7

0

0

0

5

0

H

Schedule A (Form 5500) 2007 8 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) Charges for risks or other contingencies (G) Other retention charges ..........................

Page

6
Official Use Only

▲ ▲ ▲ ▲ ▲ ▲ ▲

▲ ▲ ▲ ▲ ▲ ▲ ▲

▲ ▲ ▲ ▲ ▲ ▲ ▲

.00 .00 .00 .00 .00 .00
▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲ ▲

T

U

S E

FO

R

FI LI N
.00 .00 .00 .00 .00 .00
▲ ▲

(2) Dividends or retroactive rate refunds. (These amounts were 1) paid in cash, or 2) credited.) ..

O

N

O

(H) Total retention ..............................................................................................

▲ ▲ ▲ ▲ ▲ ▲

9

Nonexperience-rated contracts:

T

IO

N

A

L

e Dividends or retroactive rate refunds due. (Do not include amount entered in c(2).) ...................................................................

P

U R

(3)

Other reserves .....................................................................................................

P

O

S E

(2) Claim reserves .....................................................................................................

S

O N

d Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement ...............................................

LY

,D

G
.00 .00
▲ ▲

.00

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

IN FO

R

M

A

FO

R

0

5

0

7

0

0

0

6

0

I