Sample Summary Annual Report
The summary annual report furnished to participants and beneficiaries of an employee welfare benefit plan consists of a completed copy of the following form.
Summary Annual Report for [name of welfare plan]
This is a summary of the annual report of the (name of plan, EIN and type of welfare plan) for (period covered by this report). The annual report has been filed with the Internal Revenue Service, as required under the Employee Retirement Income Security Act of 1974 (ERISA).
[If any benefits under the plan are provided on an uninsured basis:]
(Name of sponsor) has committed itself to pay (all, certain) (state type of) claims incurred under the terms of the plan
[If any of the funds are used to purchase insurance contracts:]
Insurance Information
The plan has (a) contract(s) with (name of insurance carrier(s)) to pay (all, certain) (state type of) claims incurred under the terms of the plan. The total premiums paid for the plan year ending (date) were ($...).
[If applicable add:]
Because (it is a) (they are) so called experience-rated contract(s), the premium costs are affected by, among other things, the number and size of claims. Of the total insurance premiums paid for the plan year ending (date), the premiums paid under such experience-rated contract(s) were ($...) and the total of all benefit claims paid under the(se) experience-rated contract(s) during the plan year was ($...).
[If any funds of the plan are held in trust or in a separately maintained fund:]
Basic Financial Statement
The value of plan assets, after subtracting liabilities of the plan, was ($...) as of (the end of the plan year), compared to ($...) as of (the beginning of the plan year). During the plan year the plan experienced an (increase) (decrease) in its net assets of ($...). This (increase) (decrease) includes unrealized appreciation or depreciation in the value of plan assets; that is, the difference between the value of the plan's assets at the end of the year and the value of the assets at the beginning of the year or the cost of assets acquired during the year. During the plan year, the plan had total income of ($...) including employer contributions of ($...), employee contributions of ($....), realized (gains) (losses) of ($...) from the sale of assets, and earnings from investments of ($....).
Plan expenses were ($...). These expenses included ($....) in administrative expenses, ($....) in benefits paid to participants and beneficiaries, and ($...) in other expenses.
Your Rights to Additional Information
You have the right to receive a copy of the full annual report, or any part thereof, on request. The items listed below are included in that report: [Note --list only those items which are actually included in the latest annual report]
1. an accountant's report;
2. assets held for investment;
3. fiduciary information, including transactions between the plan and parties in interest (that is, persons who have certain relationships with the plan);
4. loans or other obligations in default;
5. leases in default;
6. transactions in excess of [5] percent of plan assets;
7. insurance information including sales commissions paid by insurance carriers.
To obtain a copy of the full annual report, or any part thereof, write or call the office of (name), who is (state title, e.g.: the plan administrator), (business address and telephone number). The charge to cover copying costs will be ($....) for the full annual report, or ($....) per page for any part thereof.
You also have the right to receive from the plan administrator, on request and at no charge, a statement of the assets and liabilities of the plan and accompanying notes, or a statement of income and expenses of the plan and accompanying notes, or both. If you request a copy of the full annual report from the plan administrator, these two statements and accompanying notes will be included as part of that report. The charge to cover copying costs given above does not include a charge for the copying of these portions of the report because these portions are furnished without charge.
You also have the legally protected right to examine the annual report at the main office of the plan (address), (at any other location where the report is available for examination), and at the U.S. Department of Labor in Washington, D.C., or to 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, N5507, Pension and Welfare Benefit Administration, U.S. Department of Labor, 200 Constitution Avenue, N.W., Washington, D.C. 20210