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

Date

PRINTS: FACE ONLY
INK: BLACK

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

Action

Date

Signature

O.K. to print
Revised proofs
requested

APPROVED FOR TPCC
CHAIRPERSON
"AS CORRECTED"
JOHNNY CERVANTES
12/13/2007
However, you are not required to file Form 8925 for any tax year ending
before November 14, 2007.
(January 2008)

Ref. checks
Form

[BOLD FACE]

Reviewer changes

8925

Report of Employer-Owned Life Insurance Contracts
©

(December 2007)

OMB No. 1545-2089

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

Department of the Treasury
Internal Revenue Service (99)

at the end of the tax year

Name(s) shown on return

Name of policyholder, if different from above

Attachment
Sequence No.
Identifying number

160

Identifying number, if different from above

who were insured under the contract(s) specified
Type of business

1
2
3
4a
b

issued after August 17, 2006.
See Section 1035 exchanges
below for an exception
1

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
2
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
3
for employees included on line 2
that person is (a)
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
4b
not have a valid consent
or highly

received from

tax

Related person. A related person is
General Instructions
considered a policyholder if (1) related
Section references are to the Internal
to the policyholder (defined above)
Revenue Code unless otherwise noted. under sections 267(b) or 707(b)(1), or
(b) (2) engaged in a trade or business
Purpose of Form
under common control with the
earlier
Use Form 8925 to report the number of policyholder. See sections 52(a)
and (b).
employees covered by
employer-owned life insurance
Employee. Employee includes an
contracts issued after August 17, 2006, officer, director, and highly
and the total amount of
compensated employees under section
employer-owned life insurance in force
414(q).
on those employees at the end of the
Insured. An individual must be a U.S.
tax year. Policyholders also indicate
citizen or resident to be considered
whether a valid consent has been
issued for each covered employee, and insured under an employer-owned life
insurance contract. Both individuals
the number of covered employees for
covered by a contract covering the
which a valid consent has not been
joint lives of two individuals are
received issued. See section 6039I for more
considered insured.
information.
must

Definitions
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
that / trade or business which employs the
person insured under the
employer-owned life insurance
(b) contract and (2) the direct or indirect
beneficiary of the employer-owned life
insurance contract.
(a)

Receive written

Notice and consent requirements. To
qualify as an employer-owned life
insurance contract, the policyholder
must meet the notice and consent
requirements listed below before the
issuance of the contract.
Provide
1. Written notification to the written
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 notification to the
employee that the policyholder will be
a beneficiary of any proceeds payable
upon the death of the employee.
3. Written consent from the
employee. See Valid consent under the
instructions for line 4a.

Who Must File
Generally, every policyholder owning
one or more employer-owned life

For Paperwork Reduction Act Notice, see instructions.

page 2.

Cat. No. 37737A

insurance contracts issued after
August 17, 2006, must file Form 8925
for each year the contract(s) is owned.

Section 1035 exchanges.
Policyholders are not required to
complete Form 8925 for a life
insurance contract issued after August
17, 2006, as part of a section 1035
exchange for a contract issued on or
18 2006.
before August 17,
material
However, any increase in the death
benefit or other material change to the
contract will cause it to be treated as a
new contract and the policyholder is
required to file Form 8925. For master
contracts under section 264(f)(4)(E), the
addition of covered lives is treated as a
new contract only with respect to the for /
additional covered lives.
See sections 1035 and 264(f)(4)(E) for
more information.

When and 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
Enter the name of the policyholder
(defined earlier).
ending after November 13, 2007,

Form

8925

(12-2007)

(1-2008)

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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

(1-2008)

paragraph
Page

Form 8925 (12-2007)

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Identifying Number

Paperwork Reduction Act Notice

The identifying number of an individual
is the social security number. For all
other taxpayers, it is the employer
identification number.

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.

Type of Business
Enter the policyholder’s trade or
business activity.

Line 4a

paragraph

Valid consent. Before the issuance of
the employer-owned life insurance
contract, the employee must provide
written consent (a) to be insured under
the contract and (b) that coverage may
continue after the insured terminates
employment.
s

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
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.

comma

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
estimated burden for all other
taxpayers who file this form is shown
1 hr., 00 min.
below.
Recordkeeping

2 hrs., 23 min.

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

33 min.

If you have comments concerning
the accuracy of these time estimates
or suggestions 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.
1 hr., 04 min.

Printed on recycled paper

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