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OMB No. 1545-2089
Form 8925 Report of Employer-Owned Life Insurance Contracts
(Rev. January 2010)
Attachment
Department of the Treasury © Attach to the policyholder’s tax return—See instructions. Sequence No. 160
Internal Revenue Service (99)
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 (see instructions) for each
employee included on line 2? . . . . . . . . . . . . . . . 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
that employs the person insured under reasonably expects to purchase with
General Instructions
the employer-owned life insurance regard to the employee during the
Section references are to the Internal contract and (b) the direct or indirect course of the employee's tenure.
Revenue Code unless otherwise noted. beneficiary of the employer-owned life Additional notice and consent are
Purpose of Form insurance contract. required if the aggregate face amount of
Use Form 8925 to report the number of Related person. A related person is the employer-owned life insurance
employees covered by employer-owned considered a policyholder if that person contracts with regard to an employee
life insurance contracts issued after is (a) related to the policyholder (defined exceeds the amount of which the
August 17, 2006, and the total amount of earlier) under sections 267(b) or 707(b) employee was given notice and to which
employer-owned life insurance in force (1), or (b) engaged in a trade or business the employee consented. See Q&A-9
on those employees at the end of the tax under common control with the and Q&A-12 in Notice 2009-48.
year. Policyholders must also indicate policyholder. See sections 52(a) and (b). 2. Provide written notification to the
whether a valid consent has been Employee. Employee includes an employee that the policyholder will be a
received from each covered employee, officer, director, or highly compensated beneficiary of any proceeds payable
and the number of covered employees employee under section 414(q). upon the death of the employee.
for which a valid consent has not been Insured. An individual must be a U.S. 3. Receive written consent from the
received. citizen or resident to be considered employee. See Valid consent under the
See sections 101(j) and 6039I, and insured under an employer-owned life instructions for line 4a.
Notice 2009-48, 2009-24 I.R.B. 1085, for insurance contract. Both individuals Electronic notification and consent.
more information. covered by a contract covering the joint The written notification and consent
lives of two individuals are considered requirement can be met electronically
Definitions insured. only if the system for electronic
Employer-owned life insurance Notice and consent requirements. To notification and consent meets
contract. For purposes of Form 8925, qualify as an employer-owned life requirements 1 through 3, above. See
an insurance contract is an employer- insurance contract, the policyholder Q&A-11 in Notice 2009-48 for more
owned life insurance contract if it is must meet the notice and consent information.
owned by a policyholder as defined requirements listed below before the Issue date of contract. Generally, the
below, and covers the life of the issuance of the contract. issue date of a life insurance contract is
policyholder’s employee(s) on the date the date on the policy assigned by the
1. Provide written notification to the
the life insurance contract is issued. If insurance company on or after the date
employee stating the policyholder
you have master contracts, see section of application. For purposes of meeting
intends to insure the employee’s life and
101(j)(3) for additional information. the notice and consent requirements, the
the maximum face amount for which the
Policyholder. For purposes of Form employee could be insured at the time issue date of the employer-owned life
8925 and these instructions, a the contract was issued. insurance contract is the later of (1) the
policyholder is an "applicable date of application of coverage, (2) the
policyholder" as defined in section The written notification must include
effective date of coverage, or (3) the
101(j)(3)(B). Generally, a policyholder is a disclosure of the face amount of life
formal issuance of the contract. See
the person who owns the employer- insurance, either in dollars or as a
Q&A-4 in Notice 2009-48 for more
owned life insurance contract, and who multiple of salary, that the policyholder
information.
is (a) engaged in a trade or business
For Paperwork Reduction Act Notice, see page 2. Cat. No. 37737A Form 8925 (Rev. 1-2010)
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