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Form 8925 Report of Employer-Owned Life Insurance Contracts OMB No. 1545-2089
(Rev. September 2017) ▶ Attach to the policyholder’s tax return. See instructions. Attachment
Department of the Treasury Sequence No. 160
Internal Revenue Service (99) ▶ Go to www.irs.gov/Form8925 for the latest information.
Name(s) shown on return Identifying number
Name of policyholder, if different from above Identifying number, if different from above
Type of business
1 Enter the number of employees the policyholder had at the end of the tax year . . . . . 1
2 Enter the number of employees included on line 1 who were insured at the end of the tax
year under the policyholder’s employer-owned life insurance contract(s) issued after August
17, 2006. See Section 1035 exchanges on page 2 for an exception . . . . . . . . . 2
3 Enter the total amount of employer-owned life insurance in force at the end of the tax year
for employees who were insured under the contract(s) specified on line 2 . . . . . . . 3
4 a Does the policyholder have a valid consent for each employee included on
line 2? See instructions . . . . . . . . . . . . . . . . . Yes No
b If “No,” enter the number of employees included on line 2 for whom the policyholder does
not have a valid consent . . . . . . . . . . . . . . . . . . . . . . . 4b
Section references are to the Internal Policyholder. For purposes of Form The written notification must include a
Revenue Code unless otherwise noted. 8925 and these instructions, a disclosure of the face amount of life
policyholder is an “applicable insurance, either in dollars or as a
Future Developments policyholder” as defined in section multiple of salary, that the policyholder
For the latest information about 101(j)(3)(B). Generally, a policyholder is reasonably expects to purchase with
developments related to Form 8925 and the person who owns the employer- regard to the employee during the
its instructions, such as legislation owned life insurance contract, and who course of the employee’s tenure.
enacted after they were published, go to is (a) engaged in a trade or business that Additional notice and consent are
www.irs.gov/Form8925. employs the person insured under the required if the aggregate face amount of
employer-owned life insurance contract the employer-owned life insurance
General Instructions and (b) the direct or indirect beneficiary contracts with regard to an employee
of the employer-owned life insurance exceeds the amount of which the
Purpose of Form contract. employee was given notice and to which
Use Form 8925 to report the number of Related person. A related person is the employee consented. See Q&A-9
employees covered by employer-owned considered a policyholder if that person and Q&A-12 in Notice 2009-48.
life insurance contracts issued after is (a) related to the policyholder (defined 2. Provide written notification to the
August 17, 2006, and the total amount of earlier) under sections 267(b) or 707(b) employee that the policyholder will be a
employer-owned life insurance in force (1), or (b) engaged in a trade or business beneficiary of any proceeds payable
on those employees at the end of the tax under common control with the upon the death of the employee.
year. Policyholders must also indicate policyholder. See sections 52(a) and (b). 3. Receive written consent from the
whether a valid consent has been
received from each covered employee, Employee. Employee includes an employee. See Valid consent under the
and the number of covered employees officer, director, or highly compensated instructions for line 4a.
for which a valid consent has not been employee under section 414(q). Electronic notification and consent.
received. Insured. An individual must be a U.S. The written notification and consent
citizen or resident to be considered requirement can be met electronically
For more information, see sections insured under an employer-owned life only if the system for electronic
101(j) and 6039I, and Notice 2009-48, insurance contract. Both individuals notification and consent meets
2009-24 I.R.B. 1085, available at covered by a contract covering the joint requirements 1 through 3, above. See
www.irs.gov/irb/2009-24_IRB/ar11.html. lives of two individuals are considered Q&A-11 in Notice 2009-48 for more
insured. information.
Definitions Notice and consent requirements. To Issue date of contract. Generally, the
Employer-owned life insurance qualify as an employer-owned life issue date of a life insurance contract is
contract. For purposes of Form 8925, insurance contract, the policyholder the date on the policy assigned by the
an insurance contract is an employer- must meet the notice and consent insurance company on or after the date
owned life insurance contract if it is requirements listed below before the of application. For purposes of meeting
owned by a policyholder as defined issuance of the contract. the notice and consent requirements, the
below, and covers the life of the 1. Provide written notification to the issue date of the employer-owned life
policyholder’s employee(s) on the date employee stating the policyholder insurance contract is the later of (1) the
the life insurance contract is issued. If intends to insure the employee’s life and date of application of coverage, (2) the
you have master contracts, see section the maximum face amount for which the effective date of coverage, or (3) the
101(j)(3) for additional information. employee could be insured at the time formal issuance of the contract. See
the contract was issued. Q&A-4 in Notice 2009-48 for more
information.
For Paperwork Reduction Act Notice, see instructions. Cat. No. 37737A Form 8925 (Rev. 9-2017)
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