Form 8925 Report of Employer-Owned Life Insurance Contracts

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I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 8925, PAGE 1 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
FLAT SIZE: 203 mm (8") 3 279 mm (11")
PERFORATE: NONE

PRINTS: FACE ONLY
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Form

8925

©

Name(s) shown on return

Name of policyholder, if different from above
Type of business

4a
b

Signature

O.K. to print
Revised proofs
requested

OMB No. 1545-xxxx

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Attach to the policyholder’s tax return—See instructions.

Department of the Treasury
Internal Revenue Service (99)

3

Date

Report of Employer-Owned Life Insurance Contracts

(December 2007)

1
2

Action

Attachment
Sequence No.
Identifying number

Identifying number, if different from above

Enter the number of employees the policyholder had at the end of the tax year
Enter the number of employees included on line 1 who were insured under the policyholder’s
employer-owned life insurance contract(s) at the end of the tax year
Enter the total amount of employer-owned life insurance in force at the end of the tax year
for employees included on line 2
Does the policyholder have a valid consent (see instructions) for each
employee included on line 2?
Yes
No
If “No,” enter the number of employees included on line 2 for whom the policyholder does
not have a valid consent

General Instructions
Section references are to the Internal
Revenue Code unless otherwise
noted.

Purpose of Form
Use Form 8925 to report the number
of employees covered by
employer-owned life insurance
contracts and the total amount of
employer-owned life insurance in force
on those employees at the end of the
tax year. Policyholders also indicate
whether a valid consent has been
issued for each covered employee,
and the number of covered employees
for which a valid consent has not been
issued.
Employer-owned life insurance
contract. For purposes of Form 8925,
an insurance contract is an
employer-owned life insurance
contract if it is owned by a
policyholder as defined below, and
covers the life of the policyholder’s
employee(s) on the date the life
insurance contract is issued. If you
have master contracts, see section
101(j)(3) for additional information.
Policyholder. Generally, a
policyholder is a person who is (1)
engaged in a trade or business which
employs the person insured under the
employer-owned life insurance
contract and (2) the direct or indirect
beneficiary of the employer-owned life
insurance contract.
Related person. A related person is
considered a policyholder if (1) related
to the policyholder (defined above)

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2
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4b

under sections 267(b) and 707(b)(1)
or (2) engaged in a trade or business
under common control with the
policyholder. See sections 52(a) and
(b).

Identifying Number

Employee. Employee includes an
officer, director, and highly
compensated employees under
section 414(q).
Insured. An individual must be a U.S.
citizen or resident to be considered
insured under an employer-owned life
insurance contract. Both individuals
covered by a contract covering the
joint lives of two individuals are
considered insured.

Business Activity Code

The identifying number of an individual
is the social security number. For all
other taxpayers, it is the employer
identification number.
Enter the policyholder’s six-digit
business activity code number from
the Principal Business Activity Codes
list included in the instructions for the
tax return or schedule with which the
Form 8925 is filed. If a Principal
Business Activity Code list is not
included, use the list included with the
Instructions for Form 1120.

Line 4a

Who Must File
Every policyholder owning 1 or more
employer-owned life insurance
contracts issued after August 17,
2006, must file Form 8925 for each
year the contract(s) is owned.

How to File
Attach Form 8925 to the
policyholder’s income tax return for
each tax year during which the
policyholder has employer-owned life
insurance contract(s) in force.

Recordkeeping
You must keep adequate records to
support the information reported on
Form 8925.

Specific Instructions
Name of Policyholder

Valid consent. A policyholder must
have a valid consent including the
following information from each
employee covered under an
employer-owned life insurance
contract before the contract is issued.
1. Written notification to the
employee stating the policyholder
intends to insure the employee’s life,
and the maximum face amount for
which the employee could be insured
at the time the contract was issued.
2. Written consent from the
employee to be (a) insured under the
contract, and (b) covered under the
contract after the insured terminates
employment, and
3. Written notification that the
policyholder will be a beneficiary of
any proceeds payable upon the death
of the employee.

Enter the name of the policyholder
(defined earlier).

For Paperwork Reduction Act Notice, see instructions.

Cat. No. 37737A

Form

8925

(12-2007)

5
I.R.S. SPECIFICATIONS

TO BE REMOVED BEFORE PRINTING

INSTRUCTIONS TO PRINTERS
FORM 8925, PAGE 2 of 2
MARGINS: TOP 13 mm (1⁄ 2 "), CENTER SIDES.
PAPER: WHITE WRITING, SUB. 20.
FLAT SIZE: 203 mm (8") 3 279 mm (11")
PERFORATE: NONE

PRINTS: FACE ONLY
INK: BLACK

DO NOT PRINT — DO NOT PRINT — DO NOT PRINT — DO NOT PRINT

Page

Form 8925 (12-2007)

Paperwork Reduction Act Notice.
We ask for the information on this
form to carry out the Internal Revenue
laws of the United States. You are
required to give us the information.
We need it to ensure that you are
complying with these laws and to
allow us to figure and collect the right
amount of tax.
You are not required to provide the
information requested on a form that
is subject to the Paperwork Reduction
Act unless the form displays a valid
OMB control number. Books or
records relating to a form or its

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instructions must be retained as long
as their content may become material
in the administration of any Internal
Revenue law. Generally, tax returns
and return information are confidential
as required by section 6103.

The time needed to complete and
file this form will vary depending on
individual circumstances. The
estimated burden for individual
taxpayers filing this form is approved
under OMB control number 1545-0074
and is included in the estimates
shown in the instructions for their
individual income tax return. The

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estimated burden for all other
taxpayers who file this form is shown
below.
Recordkeeping

39 min.

Learning about the law or the
form
12 min.
Preparing the form

22 min.

If you have comments concerning
the accuracy of these time estimates
or suggestion for making this form
simpler, we would be happy to hear
from you. See the instructions for the
tax return with which this form is filed.