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Form 5500 (Report of Employee Benefit Plan), Contractor - Coggle Diagram
Form 5500
(Report of Employee Benefit Plan)
Schedules
(A)
INSURANCE
Information
Benefit & Contract Type
Health (other than dental or vision) 4A
Life insurance 4B
Supplemental unemployment 4C
Dental 4D
Vision 4E
Temporary disability (accident and sickness) 4F
Prepaid legal 4G
Long-term disability 4H
Severance pay 4I
Apprenticeship and training 4J
Name of Insurance Carrier
Agent / Broker Name
$ Commissions Paid
$ Fees Paid
Agent / Broker Address
Plan Name
Effective Plan Date
Plan Sponsor Name (DBA)
Plan Sponsor Address
Plan Administrator Contact
Total # of Active Participants
Contractor
Certificate of Insurance
(
COI - ACORD 25
)