SCHEDULE A                                    Insurance Information                                                                                 OMB No. 1210-0110 
      (Form 5500)                                                       
      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 (ERISA).                                                     2022 
        Department of Labor 
 Employee Benefits Security Administration           File as an attachment to Form 5500.                                                                        
    Pension Benefit Guaranty Corporation     Insurance companies are required to provide the information                                 This Form is Open to Public 
                                                        pursuant to ERISA section 103(a)(2).                                                                 Inspection 
For calendar plan year 2022 or fiscal plan year beginning                                                                      and ending                                                        
A  Name of plan                                                                              B    Three-digit 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE                                                                        plan number (PN)                                                    001 
FGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI  
ABCDEFGHI ABCDEFGHI ABCDEFGHI                                                                 
C  Plan sponsor’s name as shown on line 2a of Form 5500                                      D  Employer Identification Number (EIN) 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE                                                                        012345678 
FGHI ABCDEFGHI  
 Part I      Information Concerning Insurance Contract Coverage, Fees, and Commissions 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 Information: 
                                                                         
(a)  Name of insurance carrier 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
 
      (b)  EIN                   (c)  NAIC      (d)  Contract or   (e)  Approximate number of                                             Policy or contract year 
                                 code        identification number     persons covered at end of                                          From                   (g)  To 
                                                                        policy or contract year                                    (f)

012345678                   ABCDE           ABCDE0123456789        1234567                                                         YYYY-MM-DD                YYYY-MM-DD 
2  Insurance fee and commission information. Enter the total fees and total commissions paid.  List in line 3 the agents, brokers, and other persons in 
 descending order of the amount paid. 
             (a) Total amount of commissions paid                                                                              (b) Total amount of fees paid 
                                            123456789012345                                                                                                  123456789012345 
3  Persons receiving commissions and fees.  (Complete as many entries as needed to report all persons). 
                                 (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
   (b) Amount of sales and base                                    Fees and other commissions paid 
      commissions paid                          (c) Amount                 (d) Purpose                                                                       (e) Organization code 
    -123456789012345                        -123456789012345       ABCDEFGHI ABCDEFGHI ABCDEFGHI                                                                        1 
                                                                   ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                                    SAMPLEABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
                                                                         
                                 (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
   (b) Amount of sales and base                                    Fees and other commissions paid 
      commissions paid                          (c) Amount                 (d) Purpose                                                                       (e) Organization code 
    -123456789012345                        -123456789012345       ABCDEFGHI ABCDEFGHI ABCDEFGHI                                                                        1 
                                                                   ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                                                   ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
For Paperwork Reduction Act Notice, see the Instructions for Form 5500.                                                                                 Schedule A (Form 5500) 2022 
                                                                                                                                                                                                 v. 220413 
                                                                                                                                                                                                     

   Schedule A  (Form 5500) 2022                  Page   2 – 1  x                                                                    
                                                
                    (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
                                              Fees and other commissions paid                                         (e) 
(b) Amount of sales and base                                                                                          Organization 
   commissions paid             (c) Amount                  (d) Purpose                                               code 
-123456789012345             -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI                                           1 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
                                                 
                    (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
                                              Fees and other commissions paid                                         (e) 
(b) Amount of sales and base                                                                                          Organization 
   commissions paid             (c) Amount                  (d) Purpose                                               code 
-123456789012345             -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI                                           1 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
                                                
                    (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
                                              Fees and other commissions paid                                         (e) 
(b) Amount of sales and base                                                                                          Organization 
   commissions paid             (c) Amount                  (d) Purpose                                               code 
-123456789012345             -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI                                           1 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
                                                
                    (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
                                              Fees and other commissions paid                                         (e) 
(b) Amount of sales and base                                                                                          Organization 
   commissions paid             (c) Amount                  (d) Purpose                                               code 
-123456789012345             -123456789012345SAMPLE ABCDEFGHI ABCDEFGHI ABCDEFGHI                                     1 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
                                                
                    (a) Name and address of the agent, broker, or other person to whom commissions or fees were paid 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
123456789 ABCDEFGHI ABCDEFGHI ABCDE 
CITY56789 ABCDEFGHI AB, ST 021345678901 
                                              Fees and other commissions paid                                         (e) 
(b) Amount of sales and base                                                                                          Organization 
   commissions paid             (c) Amount                  (d) Purpose                                               code 
-123456789012345             -123456789012345 ABCDEFGHI ABCDEFGHI ABCDEFGHI                                           1 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                              ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDE 

                Schedule A  (Form 5500) 2022                                                                            Page  3

   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. 
0B4  Current value of plan’s interest under this contract in the general account at year end ...............................................                                       4    123456789012345 
1B5  Current value of plan’s interest under this contract in separate accounts at year end .................................................                                       5    123456789012345 
2B6  Contracts With Allocated Funds:                                                                                                                                                                    
     3Ba      State the basis of premium rates                                                                                                                                    
                                                        
     4Bb      Premiums paid to carrier ....................................................................................................................................        6b   -123456789012345 
     5Bc      Premiums due but unpaid at the end of the year ................................................................................................                      6c   -123456789012345 
     6Bd      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. ................................................................................................                  6d   -123456789012345 
             Specify nature of costs                                                                                                                                                                   
                                                                                                                                                                                                        
     7Be      Type of contract:   (1)    Xindividual policies                (2)     Xgroup deferred annuity                                                                                            
              8B(3)     Xother (specify)                                                                                                                                           
                                                      
       f9B    If contract purchased, in whole or in part, to distribute benefits from a terminating plan, check here        X                                                         
10B7  Contracts With Unallocated Funds (Do not include portions of these contracts maintained in separate accounts)                                                                      
                                                                                     13B
      11Ba    Type of contract:    12B(1)    Xdeposit administration                    (2)    Ximmediate participation guarantee                                                        
                                                                                     15B
                                   14B(3)    Xguaranteed investment                     (4)    Xother  
                                                                                                                         
      16Bb    Balance at the end of the previous year .............................................................................................................                7b   123456789012345 
      17Bc    Additions:  (1) Contributions deposited during the year ...............................                  7c(1)   -123456789012345                                          
              (2) Dividends and credits .............................................................................  7c(2)   -123456789012345                                          
              (3) Interest credited during the year .............................................................      7c(3)   -123456789012345                                          
              (4) Transferred from separate account ........................................................           7c(4)   -123456789012345                                          
              (5) Other (specify below) .............................................................................  7c(5)   -123456789012345                                          
                                                                                                                        
                                                                                                                         
              (6)Total additions ...............................................................................................................................................  7c(6) 123456789012345 
        d 18B Total of balance and additions (add lines7b and 7c(6)).  ....................................................................................                        7d   123456789012345 
       19Be  Deductions:                                                                                                                                                                 
            (1) Disbursed from fund to pay benefits or purchase annuities during year                                  7e(1)   -123456789012345                                          
            (2) Administration charge made by carrier ....................................................             7e(2)   -123456789012345                                          
            (3) Transferred to separate account .............................................................          7e(3)   -123456789012345                                          
            (4) Other (specify below) ..............................................................................   7e(4)   -123456789012345                                          
                                                                                                                        
                                                             SAMPLE
                                                                                                                         
            (5) Total deductions ............................................................................................................................................     7e(5) 123456789012345 
        f20B  Balance at the end of the current year (subtract line7e(5) from line7d) .............................................................                                7f   123456789012345 

             Schedule A  (Form 5500) 2022                                                                                  Page     4                                                            

                   Welfare Benefit Contract Information                                                                                                                                                              
   Part III 
                   If more than one contract covers the same group of employees of the same employer(s) or members of the same employee organizations(s), 
                   the information may be combined for reporting purposes if such contracts are experience-rated as a unit.  Where contracts cover individual 
                   employees, the entire group of such individual contracts with each carrier may be treated as a unit for purposes of this report. 
21B8   Benefit and contract type (check all applicable boxes) 
      22Ba  X  Health (other than dental or vision)               23Bb X   Dental                                          24Bc     X  Vision                                         25Bd X    Life insurance 
      26Be   X  Temporary disability (accident and sickness)      27Bf  X  Long-term disability                            28Bg     X  Supplemental                                   29Bh X    Prescription drug 
                                                                                                                                     unemployment 
      30Bi  X  Stop loss (large deductible)                       31Bj  X  HMO contract                                    32Bk     X  PPO contract                                     l33B X  Indemnity contract 
      34Bm   X  Other (specify)  ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
                                          ABCKEFGHI ABCDEFGHI ABCDEFGHI ABCDE 
35B9  Experience-rated contracts:                                                                                                                                                         
      36Ba   Premiums: (1) Amount received................................................................                 9a(1)        -123456789012345                                  
            (2) Increase (decrease) in amount due but unpaid ...................................                           9a(2)        -123456789012345                                  
            (3) Increase (decrease) in unearned premium reserve .............................                              9a(3)        -123456789012345                                  
             (4) Earned ((1)  +(2)  (3) - ) .................................................................................................................................. 9a(4)         123456789012345 
        b37B Benefit charges (1) Claims paid ...............................................................               9b(1)        -123456789012345                                                             
            (2) Increase (decrease) in claim reserves .................................................                    9b(2)        -123456789012345                                  
            (3) Incurred claims (add (1) and (2)) ................................................................................................................             9b(3)         123456789012345 
            (4) Claims charged ..........................................................................................................................................      9b(4)         123456789012345 
        c38B Remainder of premium: (1) Retention charges (on an accrual basis) --                                                       -123456789012345                                                             
                   (A) Commissions ...............................................................................         9c(1)(A)     -123456789012345                                                             
                   (B) Administrative service or other fees .............................................                  9c(1)(B)     -123456789012345                                                             
                   (C) Other specific acquisition costs ....................................................               9c(1)(C)     -123456789012345                                                             
                   (D) Other expenses ...........................................................................          9c(1)(D)     -123456789012345                                                             
                   (E) Taxes ...........................................................................................   9c(1)(E)     -123456789012345                                                             
                   (F) Charges for risks or other contingencies ......................................                     9c(1)(F)     -123456789012345                                                             
                   (G) Other retention charges ...............................................................             9c(1)(G)     -123456789012345                                                             
                   (H) Total retention.....................................................................................................................................    9c(1)(H)      123456789012345 
            (2)39B Dividends or retroactive rate refunds.  (These amounts were   Xpaid in cash, or    credited.)X                       .................                      9c(2)         123456789012345 
        d40B Status of policyholder reserves at end of year: (1) Amount held to provide benefits after retirement ...............                                              9d(1)         123456789012345 
            (2) Claim reserves ..........................................................................................................................................      9d(2)         123456789012345 
             (3) Other reserves ..........................................................................................................................................     9d(3)         123456789012345 
        e41B Dividends or retroactive rate refunds due.  (Do not include amount entered in line9c(2).) ..............................                                             9e         123456789012345 
42B10    Nonexperience-rated contracts:                                                                                                                                                   
        a43B Total premiums or subscription charges paid to carrier ...................................................................................                        10a           123456789012345 
        b44B 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, line 2 above, report amount. .........................                                        10b           123456789012345 
      Specify nature of costs.   
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHISAMPLEABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCD 
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI  
 
   Part IV          Provision of Information  
45B11    Did the insurance company fail to provide any information necessary to complete Schedule A? .............                                     X                       Yes      X    No 
12       If the answer to line 11 is “Yes,” specify the information not provided.   
ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI ABCDEFGHI 
         ABCDEFGHI ABCDE