FORM 5500 DATA COLLECTION FORM

Company name:
Plan year: / Part of controlled group of companies:
¨ Yes ¨ No
Tax id #: / Telephone number:
Three digit plan # (501): / Initial effective date of plan:
Business code (six digit code): / Collectively bargained plan (union):
¨ Yes ¨ No
Street address:
City: / State: / Zip:

Welfare Benefit Plan Documents

(Please provide the following documents for all of your welfare benefit plans)

·  Latest welfare benefit plan Form 5500

·  Copy of welfare benefit plan documents (i.e., plan document, summary plan description)

·  Copy of trust document(s) (if applicable)

·  Schedule A information from any insured welfare benefit plan

Welfare Benefit Plan Information

Welfare Benefit Plan / Name of Carrier/Administrator / Funding
Medical / ¨ Yes
¨ No / ¨ Fully insured
¨ Self-funded
Prescription Drug / ¨ Yes
¨ No / ¨ Fully insured
¨ Self-funded
Dental / ¨ Yes
¨ No / ¨ Fully insured
¨ Self-funded
Vision / ¨ Yes
¨ No / ¨ Fully insured
¨ Self-funded
Employee Term Life / ¨ Yes
¨ No / ¨ Fully insured
¨ Self-funded
Dependent Term Life / ¨ Yes
¨ No / ¨ Fully insured
¨ Self-funded
Short-term Disability / ¨ Yes
¨ No / ¨ Fully insured
¨ Self-funded
Long-term Disability / ¨ Yes
¨ No / ¨ Fully insured
¨ Self-funded
Health Care FSA / ¨ Yes
¨ No / ¨ Admin by TPA
¨ Internal Admin
Employee Asst. Plan / ¨ Yes
¨ No
Pre-paid legal / ¨ Yes
¨ No
Scholarship funds / ¨ Yes
¨ No
Other: / ¨ Yes
¨ No

Any plan funding via a welfare benefit plan trust? If yes, identify the plan(s): ______

______

______

Welfare Benefit Plan Participant Count

Form 5500 Participant Definition # of Participants

Number of Participants at the beginning of the year
Number of participants as of the end of the plan year
1. Active Participants
2. Retired or separated participants receiving benefits
3. Other retired or separated participants entitled to future benefits
4. Deceased participants whose beneficiaries are receiving or are entitled to
received benefits

The definition of “participant” for purposes of the Form 5500 is defined below. The number of covered participants reported here includes covered employees plus COBRA qualified beneficiaries, but not children covered by a qualified medical child support order (QMCSO). Individuals covered by more than one component benefit program of the filing plan are counted only once for this purpose.

"Participant" means any individual who is included in one of the categories below:

1. Active participants include any individuals who are currently covered by a plan and who are earning or retaining credited service under a plan. This category does not include

(a) nonvested former employees who have incurred the break in service period specified in the plan or

(b) former employees who have received a "cash-out" distribution or deemed distribution of their entire nonforfeitable accrued benefit.

2. Retired or separated participants receiving benefits are any individuals who are retired or separated from employment covered by the plan and who are receiving benefits under the plan. This includes former employees who are receiving group health COBRA continuation coverage benefits and who are covered by the employee welfare benefit plan. This category does not include any individual to whom an insurance company has made an irrevocable commitment to pay all the benefits to which the individual is entitled under the plan.

3. Other retired or separated participants entitled to future benefits are any individuals who are retired or separated from employment covered by the plan and who are entitled to begin receiving benefits under the plan in the future. This category does not include any individual to whom an insurance company has made an irrevocable commitment to pay all the benefits to which the individual is entitled under the plan.

4. Deceased individuals who had one or more beneficiaries who are receiving or are entitled to receive benefits under the plan. This category does not include an individual if an insurance company has made an irrevocable commitment to pay all the benefits to which the beneficiaries of that individual are entitled under the plan.