Form 8925
(Rev. September 2017)
Department of the Treasury
Internal Revenue Service (99)
Report of Employer-Owned Life Insurance Contracts
▶
Attach to the policyholder’s tax return. See instructions.
▶
Go to www.irs.gov/Form8925 for the latest information.
OMB No. 1545-2089
Attachment
Sequence No.
160
Name(s) shown on return Identifying number
Name of policyholder, if different from above
Identifying number, if different from above
Type of business
1 Enter the number of employees the policyholder had at the end of the tax year . . . . . 1
2 Enter the number of employees included on line 1 who were insured at the end of the tax
year under the policyholder’s employer-owned life insurance contract(s) issued after August
17, 2006. See Section 1035 exchanges on page 2 for an exception . . . . . . . . .
2
3 Enter the total amount of employer-owned life insurance in force at the end of the tax year
for employees who were insured under the contract(s) specified on line 2 . . . . . . .
3
4 a
Does the policyholder have a valid consent for each employee included on
line 2? See instructions . . . . . . . . . . . . . . . . .
Yes No
b If “No,” enter the number of employees included on line 2 for whom the policyholder does
not have a valid consent . . . . . . . . . . . . . . . . . . . . . . . 4b
Section references are to the Internal
Revenue Code unless otherwise noted.
Future Developments
For the latest information about
developments related to Form 8925 and
its instructions, such as legislation
enacted after they were published, go to
www.irs.gov/Form8925.
General Instructions
Purpose of Form
Use Form 8925 to report the number of
employees covered by employer-owned
life insurance contracts issued after
August 17, 2006, and the total amount of
employer-owned life insurance in force
on those employees at the end of the tax
year. Policyholders must also indicate
whether a valid consent has been
received from each covered employee,
and the number of covered employees
for which a valid consent has not been
received.
For more information, see sections
101(j) and 6039I, and Notice 2009-48,
2009-24 I.R.B. 1085, available at
www.irs.gov/irb/2009-24_IRB/ar11.html.
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. For purposes of Form
8925 and these instructions, a
policyholder is an “applicable
policyholder” as defined in section
101(j)(3)(B). Generally, a policyholder is
the person who owns the employer-
owned life insurance contract, and who
is (a) engaged in a trade or business that
employs the person insured under the
employer-owned life insurance contract
and (b) the direct or indirect beneficiary
of the employer-owned life insurance
contract.
Related person. A related person is
considered a policyholder if that person
is (a) related to the policyholder (defined
earlier) under sections 267(b) or 707(b)
(1), or (b) engaged in a trade or business
under common control with the
policyholder. See sections 52(a) and (b).
Employee. Employee includes an
officer, director, or highly compensated
employee 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.
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.
1. Provide 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.
The written notification must include a
disclosure of the face amount of life
insurance, either in dollars or as a
multiple of salary, that the policyholder
reasonably expects to purchase with
regard to the employee during the
course of the employee’s tenure.
Additional notice and consent are
required if the aggregate face amount of
the employer-owned life insurance
contracts with regard to an employee
exceeds the amount of which the
employee was given notice and to which
the employee consented. See Q&A-9
and Q&A-12 in Notice 2009-48.
2. Provide written notification to the
employee that the policyholder will be a
beneficiary of any proceeds payable
upon the death of the employee.
3. Receive written consent from the
employee. See Valid consent under the
instructions for line 4a.
Electronic notification and consent.
The written notification and consent
requirement can be met electronically
only if the system for electronic
notification and consent meets
requirements 1 through 3, above. See
Q&A-11 in Notice 2009-48 for more
information.
Issue date of contract. Generally, the
issue date of a life insurance contract is
the date on the policy assigned by the
insurance company on or after the date
of application. For purposes of meeting
the notice and consent requirements, the
issue date of the employer-owned life
insurance contract is the later of (1) the
date of application of coverage, (2) the
effective date of coverage, or (3) the
formal issuance of the contract. See
Q&A-4 in Notice 2009-48 for more
information.
For Paperwork Reduction Act Notice, see instructions.
Cat. No. 37737A
Form 8925 (Rev. 9-2017)
