Labor Organization and Auxiliary Reports

Public reporting burden for this collection of information is estimated to average 35 minutes, including the time for reviewing
instructions, searching existing data sources, gathering and maintaining the data needed, and completing and reviewing the collection
of information. Persons are not required to respond to the collection of information unless it displays a currently valid OMB control
number. Reporting of this information is mandatory and is required by the Labor-Management Reporting and Disclosure Act of 1959,
as amended, for the purpose of public disclosure. As this is public information, there are no assurances of confidentiality. If you have
any comments regarding this estimate or any other aspect of this information collection, including suggestions for reducing this burden,
please send them to the U.S. Department of Labor, Employment Standards Administration, Office of Labor-Management Standards,
Division of Interpretations and Standards, Room N-5605, 200 Constitution Avenue, NW, Washington, DC 20210.

DO NOT SEND YOUR COMPLETED FORM S-1 TO THE ABOVE ADDRESS

INSTRUCTIONS FOR FORM S-1
SURETY COMPANY ANNUAL REPORT
GENERAL INSTRUCTIONS
The completed Form S-1 and any required
attachments and additional pages must be mailed to
the following address:

I. WHY FILE
The Labor-Management Reporting and Disclosure Act of
1959, as amended (LMRDA), requires public disclosure
of financial information from any surety company which
issues a bond required by the LMRDA or the Employee
Retirement Income Security Act of 1974 (ERISA). The
Secretary, under the authority of the LMRDA, has
prescribed the filing of the Surety Company Report,
Form S-1, for surety companies to satisfy this reporting
requirement.

U.S. Department of Labor
Employment Standards Administration
Office of Labor-Management Standards
200 Constitution Avenue, NW
Room N-5616
Washington, DC 20210
VII. PUBLIC DISCLOSURE

II. WHO MUST FILE

Pursuant to the LMRDA, the U.S. Department of Labor is
required to make all submitted reports available for
public inspection. You may examine Form S-1 reports
at, and purchase copies from, the Office of LaborManagement Standards (OLMS) Public Disclosure
Room at the address listed in Section VI, or at the OLMS
field office in whose jurisdiction the reporting
organization is located. At the end of these instructions
is a list of OLMS field offices.

Form S-1 must be filed by any surety company having a
bond in force which insures the following: (1) a welfare
or pension plan covered by the ERISA; or (2) any labor
organization or trust in which a labor organization is
interested covered by the LMRDA. A single report for a
group of surety companies will not be accepted.
III. WHAT MUST BE REPORTED
Any surety company required to file Form S-1 must
report financial information regarding its bond
experience under the LMRDA and the ERISA, including
premiums received, total claims paid, amounts
recovered by way of subrogation, administrative and
legal expenses, and related data and information.

VIII. OFFICER RESPONSIBILITIES AND PENALTIES
The president and treasurer or corresponding principal
officers of the surety company required to sign Form S-1
are personally responsible for its filing and accuracy.
Under the LMRDA, these individuals are subject to
criminal penalties for willful failure to file a required
report and/or false reporting. False reporting includes
making any false statement or misrepresentation of a
material fact while knowing it to be false, or for knowingly
failing to disclose a material fact in a required report or in
the information required to be contained in it or in any
information required to be submitted with it.

IV. WHO MUST SIGN THE REPORT
Both the president and the treasurer or corresponding
principal officers of the surety company must sign the
completed Form S-1. You do not need to have the
report notarized.
V. WHEN TO FILE

The reporting surety company and the officers required
to sign Form S-1 are also subject to civil prosecution for
violations of the filing requirements. Section 210 of the
LMRDA provides that “whenever it shall appear that any
person has violated or is about to violate any of the

Each surety company required to file a report under the
LMRDA must file Form S-1 within 150 days after the end
of its fiscal year.
VI. WHERE TO FILE
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2003 were assigned four-digit file numbers. OLMS has
now expanded file numbers to five digits. Place a zero
in front of your old four-digit file number to meet the new
format requirement. For example, if your old file number
was 1234, enter 01234 in Item 1 of this year’s report. If
you have never previously filed the Form S-1, leave this
space blank.

provisions of this title, the Secretary may bring a civil
action for such relief (including injunctions) as may be
appropriate.”
IX. RECORDKEEPING
The individuals required to file Form S-1 are responsible
for maintaining records which must provide in sufficient
detail the information and data necessary to verify the
accuracy and completeness of the report. You must
retain the records for at least 5 years after the date the
report is filed. You must retain any record necessary to
verify, explain, or clarify the report including, but not
limited to, vouchers, worksheets, receipts, and
applicable resolutions.

2. YEAR ENDING — Enter the month, day, and year of
the ending date of the fiscal year covered by this report.
3. NAME OF SURETY COMPANY— Enter the full legal
name of the surety company filing this report.
4. ADDRESS OF PRINCIPAL OFFICE—Enter the
complete address of the surety company where mail
should be sent and received, including any building and
room number.

Individuals are subject to penalties for willfully making
any false entry in or concealing, withholding, or
destroying any books, records, or statements required to
be kept.

Special Instructions for Completing PARTS II and III

ƒ You must report the information on the basis of the

X. COMPLETING FORM S-1

following code classifications as described in the
Fidelity Uniform Statistical Plan of the Surety
Association of America:

Read these instructions carefully before completing Form
S-1.
Information Entry. Entries on the report should be
typed or clearly printed in black ink. Do not use a pencil
or any other color ink.

LMRDA
Labor Unions - National or International Unions
Only………… …………………………………….691

Entering Dollars. In all Items dealing with monetary
values, report amounts in dollars only; do not enter
cents. Round cents to the nearest dollar. Enter a single
“0” in the boxes for reporting dollars if the surety
company has nothing to report.

Labor Unions - Local Unions Only……………...692
Labor Unions - National or International Unions including
Local Unions Under a Single
Policy………..……………………………………695

Entering Dollars:

ERISA

$1,573,844 — do not enter cents

Labor Unions - Health, Welfare and Pension Plans and
Trusts of…........................................…….697

Entering Zero:

Pension Retirement and Welfare Plans (non-profit) Other Than Labor Unions…….....……..872

$_,_ _ _, _ _ 0
Additional Pages. If you need additional space to
complete an item, enter the additional information on a
separate letter-size (8.5 x 11) page(s), indicating the
number of the item to which the information applies.
Print clearly at the top of each attached page the
following information: (1) full name of the surety
company, (2) its file number as reported in Item 1 of
Form S-1, and (3) the ending date of the reporting period
as reported in Item 2. All attachments must be labeled
sequentially 1 of_, 2of_,etc.

ƒ The figures you report should not reflect any
reinsurance assumed or ceded.

PART II — PREMIUM DATA
5. DIRECT PREMIUMS WRITTEN—Enter the Gross
Premiums (including Co-Surety) written or renewed
during the year, less Returns. See Special Instructions
above.

NOTE: Separate space is provided for reporting
experience figures for “Honesty” and “Faithful Discharge”
contracts.

6. DIRECT PREMIUMS EARNED—Enter the sum of
the “Direct Premiums Written” and the Unearned
Premium at the end of the preceding year less the
Unearned Premium at the end of the current year.

PART I — IDENTIFICATION
1. FILE NUMBER — Enter the five-digit file number
assigned by OLMS for the reporting surety company.
Surety companies that filed a Form S-1 prior to October

7. EXPENSES INCURRED-OTHER THAN LOSS
ADJUSTMENT—Enter the sum of the following items
allocable to the premiums reported herein as reflected in
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Part II of the Insurance Expense Exhibit filed under State
law:

PART IV—ITEMIZATION OF LOSSES REPORTED
DURING YEAR

Line 6 - Commission and Brokerage incurred

15. REPORT INFORMATION FOR EACH LOSS FOR
WHICH A NOTICE WAS RECEIVED DURING THE
REPORT YEAR—Complete Item 15 with reference to
each Notice of Loss received during the report year
involving a welfare or pension plan covered by the
ERISA or involving any labor organization or trust in
which a labor organization is interested, either of which
is covered by the LMRDA. You must complete this Item
whether or not such welfare or pension plan, labor
organization, or trust is insured under a contract as
reported in Parts Il and III above.

Line 7 - Other Acquisition, Field Supervision and
Collection Expenses Incurred.
Line 13 - General Expenses Incurred.
Line 14 - Taxes, Licenses, and Fees Incurred.
NOTE: Those amounts allocable to lines 7 and 13 may
be in the proportion to total expenses of lines 7 and 13
that the premiums reported herein bear to total fidelity
premiums.

a. Date notice of loss received—Enter the date
(month, day, year) that you received notice of the
loss. Enter either (1) the date Notice of Loss was
received or (2) the date reserve was posted. The
basis selected must be used for all such entries.

8. PERCENT OF DIRECT PREMIUMS EARNED—
Calculate the percent of the direct premiums earned
allocated to net losses by dividing the amount in Item 7
(Expenses Incurred – Other than Loss Adjustment) by
the amount in Item 6 (Direct Premiums Earned). Enter
the total in Item 8.

b. Name and Address of Insured Sustaining Loss
Organization Name—Enter the full name and
complete mailing address of the insured
organization sustaining the loss, including Building
and room number, if any.

PART III — LOSS DATA
9. DIRECT LOSSES PAID—Enter the losses paid on
direct business only. The losses should not reflect
adjustments for salvage.

c. Bond Class Code—Enter the Surety Association
classification code to which loss is charged.

10. DIRECT LOSSES INCURRED—Enter the sum of
“Direct Losses Paid” and “Direct Losses Unpaid of the
current year less Direct Losses Unpaid from the previous
year. Include losses Incurred But Not Reported
estimated on a basis of relationship to the total Fidelity
line.

d. Amount of Bond Coverage Available—Enter
the amount of the available bond coverage.
e. Gross Loss to Insured (if known)—Enter the
gross loss of the insured, if known.
f. Amount Paid to Insured in Report Year—Enter
the amount you paid to the insured during the
reporting year.

11. DIRECT LOSS ADJUSTMENT EXPENSES
INCURRED—Enter the portion of Part II, Line 5, Column
20 of Insurance Expense Exhibit filed Under State law
which is allocable to “Direct Losses Incurred.”

g. Amount of Salvage Recovered in Report
Year—Enter the amount of salvage recovered
during the reportable year.

12. DIRECT SALVAGE RECOVERED—Enter only the
salvage recovered during the current year on “Direct
Losses Paid” in the current or prior years (net as to any
recovery expenses).

ADDITIONAL INFORMATION AND SIGNATURES
16. ADDITIONAL INFORMATION—Enter any
additional information necessary for completing an
item. You must indicate the item to which the
additional information applies.

13. NET LOSSES—Calculate the net losses by adding
the amount in Item 10 (Direct Losses Incurred) to the
amount in Item 11 (Direct Loss Adjustment Expenses
Incurred), then subtracting the amount in Item 12 (Direct
Salvage Recovered). Enter the total in Item 13.

17-18. SIGNATURES—The completed Form S-1 which
is filed with OLMS must be signed by the president and
treasurer, or corresponding principal officers, of the
surety company. This report must bear two (2)
signatures. If the report is signed by an officer other
than the president and/or treasurer, so indicate in Items
17 and/or 18 by (1) crossing out the pre-printed officer
title(s) and (2) inserting the appropriate officer title(s).
You must have original signatures on the Form S-1 filed

14. PERCENT OF DIRECT PREMIUMS EARNED
ALLOCATED TO NET LOSSES—Calculate the percent
of direct premiums earned allocated to net losses by
dividing the amount in Item 13 (Net Losses) by the
amount in Item 6 (Direct Premiums Earned). Enter the
total in Item 14.

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with OLMS; stamped or mechanical signatures are not
acceptable.

for the year 1999 and earlier can be ordered through the
website.

Enter the date the report was signed and the telephone
number(s) used by signatories to conduct official
business. You do not have to report a private, unlisted
telephone number.

Information about OLMS, including key personnel and
telephone numbers, compliance assistance materials,
the text of the LMRDA, and related Federal Register and
Code of Federal Regulations (CFR) documents, is also
available on the Internet at:

Contact the nearest OLMS field office listed below if
you have questions about filing a surety company
annual report.

http://www.olms.dol.gov

If You Need Assistance
The Office of Labor-Management Standards has field
offices located in the following cities to assist you if you
have any questions concerning LMRDA and CSRA
reporting requirements.
Atlanta, GA
Birmingham, AL
Boston, MA
Buffalo, NY
Chicago, IL
Cincinnati, OH
Cleveland, OH
Dallas, TX
Denver, CO
Detroit, MI
Grand Rapids, MI
Guaynabo, PR
Honolulu, HI
Houston, TX
Kansas City, MO
Los Angeles, CA
Miami (Ft. Lauderdale), FL
Milwaukee, WI
Minneapolis, MN
Nashville, TN
New Haven, CT
New Orleans, LA
New York, NY
Newark (Iselin), NJ
Philadelphia, PA
Pittsburgh, PA
St. Louis, MO
San Francisco, CA
Seattle, WA
Tampa, FL
Washington, DC
Consult local telephone directory listings under United
States Government, Labor Department, Office of LaborManagement Standards, for the address and telephone
number of the nearest field office.
Copies of labor organization annual financial reports,
employer reports, and labor relations consultant reports
filed for the year 2000 and after can be viewed and
printed at www.union-reports.dol.gov. Copies of reports

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