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FORM 5500

Instructions: Complete this form to request Form 5500 services. 5500 filings are required for all group health plans with 100 or more participating employees.  For assistance determining if your company is required to file a Form 5500, please contact your KTB agent at 1-800-396-4309.

Total # of Plan Participants at Beginning of Plan Year
Total # of Plan Participants at End of Plan Year
Company Information ( All fields are required)
KTB Broker Name
Employer Name
Employer Address
 
Employer City
Employer State
Employer Zip
Employer Telephone #
Employer Tax I.D. #
Plan Name
Is this the first year a 5500 was required?
If no, did KTB complete the 5500 for the previous year?
*If a 5500 was required for the previous year and KTB did not complete the filing please provide a copy of last year’s report*
Original Effective Date Of Plan
Plan Year Beginning Date
Plan Year Ending Date
Single Employer Plan
 Collectively Bargained Plan (Union involved)

Include all benefits provided by the group health plan, including medical, dental, vision, life, disability, FSA, HRA, HSA, EAP.

   
Schedule A
(List the type of coverage included for each Schedule A provided, such as Medical, Life, etc.)		 Name of Insurance Carrier
( List each Company)
 
 
Please also provide the following: Copy of Last Year's completed Form 5500
Copy of Last Year's Summary Annual Report
 




Customer Services


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