Sample Summary Annual Report for abc company Flex Plan


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Sample Summary Annual Report for ABC Company Flex Plan

Caution: EBIA's sample documents are for a hypothetical employer and may not apply to your factual situation. They are provided here for illustrative purposes only, and may not be used "as is" for any purpose. See the Caution & Use Restriction box.



This is a summary of the Form 5500 annual report of the ABC Company Flex Plan (Plan), EIN 77-7777777, Plan No. 501, a welfare benefit plan sponsored by ABC Company, for the period of January 1, 2013 through December 31, 2013. The Form 5500 annual report has been filed with the Employee Benefits Security Administration, as required under the Employee Retirement Income Security Act of 1974 (ERISA).

The Plan provides welfare benefits through a cafeteria plan established under Section 125 of the Internal Revenue Code. The Plan also includes a dependent care account component. The cafeteria plan component and the dependent care component are not covered by ERISA, and they are not included in this ERISA-required summary. This summary reports on only the ERISA-covered components of the ABC Company Flex Plan listed below:



  1. Health Flexible Spending Arrangement (Health FSA)

  2. Group Health Insurance

  3. Group Dental Insurance

  4. Group Term Life (GTL) Insurance

  5. Group LTD Insurance

  6. Group AD&D Insurance



Uninsured Components Benefits under the Health Flexible Spending Arrangement (Health FSA) component of the Plan are not funded. ABC Company has committed itself to pay these benefits out of its general assets.
Insured Components-Insurance Information All components of the plan other than the Health FSA component are provided through insurance contracts. The name of the insurer, type of benefit provided, and premiums paid for each component are set forth in the table below. The total amount of premiums paid for the plan year ending December 31, 2013, is $770,000.


Type of Benefit

Name of Insurer

Premiums Paid

Group Health Insurance

Health Insurance Company

$500,000

Group Dental Insurance

Dental Insurance Company

$100,000

Group Term Life (GTL) Insurance

GTL Insurance Company

$50,000

Group LTD Insurance

LTD Insurance Company

$70,000

Group AD&D Insurance

LTD Insurance Company

$50,000



The Group Health Policy with the Health Insurance Company is a so-called "experience-rated" contract. As such, the premium costs are affected by, among other things, the number and size of claims. Of the total insurance premiums paid under the Plan for the plan year ending December 31, 2013 ($770,000), the premiums paid under the Group Health Policy "experience-rated" contract were $500,000 and the total of all benefit claims paid under this contract during the plan year was $400,000.
Your Rights to Additional Information You have the right to receive a copy of the full annual report, or any part thereof, on request. The items listed below are included in that report:



  1. insurance information including sales commissions paid by insurance carriers (if any); and

  2. fiduciary information, including nonexempt transactions (if any) between the plan and parties in interest (that is, persons who have certain relationships with the plan).


To obtain a copy of the full annual report, or any part thereof, write to Edith Day, who is the Human Resources Manager of ABC Company, at 987 State Street, Yourtown, GA 99999, or call her at (444) 123-4567. The charge to cover copying costs will be $3.00 for the full annual report, or $.25 per page for any part thereof.
You also have the legally protected right to examine the annual report at the main office of ABC Company and at the U.S. Department of Labor in Washington, D.C., or you may obtain a copy from the U.S. Department of Labor upon payment of copying costs. Requests to the Department should be addressed to: Public Disclosure Room, N1513, Employee Benefits Security Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210.

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© 2014 Thomson Reuters/EBIA. All rights reserved.
© 2014 Thomson Reuters/Tax & Accounting. All Rights Reserved.


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