- Company information and quarter ending "June 2016"
- Part II, IRS No. 133
- Column (a), row (b) - enter “Avg. number of lives covered for self-insured health plans”
- Column (b) – see instructions ($2.08 or $2.17, depending on end of plan year)
- Column (c) – enter total Fee (lives x $)
- Tax column – enter the amount of the fee (from Column (c))
- Part II, Line 2 – enter Total Tax (from Tax column on No. 133)
- Part III, Line 3 – enter Total Tax (from Part II, Line 2)
- Part III, Line 10 – enter Balance Due (from Part III, Line 3)
- Signature section
- Payment voucher with “2nd Quarter” checked, or file and pay electronically
- If filing by mail, send the form, payment voucher, and check to:
- Department of the Treasury
- Internal Revenue Service
- Cincinnati, OH 45999-0009
Snapshot method – At least one date during each month of each quarter. Dates in each quarter must be within 3 days of the dates for corresponding quarters.
Form 5500 method – Use participant counts from the 5500 for that plan for that year.
Kristen Russell
Kristen founded Fall River Employee Benefits as the culmination of her insurance industry career as an actuary, underwriting executive & consultant. As an Assistant Vice President at Great-West Healthcare (now part of CIGNA), she managed a $1 Billion block of health insurance. She also worked as a Senior Consultant at Reden & Anders, consulting to insurance companies and large employers throughout the country. Ms. Russell received a Bachelor of Science, Business Administration in Actuarial Science, is a member of the American Academy of Actuaries and achieved Fellowship in the Society of Actuaries through a rigorous nine-year series of exams.
Kristen grew up in Iowa but has lived in Colorado since 1993, currently living near our office in the Lower Highlands neighborhood near downtown Denver. She enjoys bicycling, hiking, traveling and has a special passion for non-profit volunteering. She is married to an incredibly talented photojournalist, has two adult stepdaughters and an adorable Border Collie/Lab mix named Chaco.