Instructions for Part I - General Plan Information

1 Plan sponsor information

1. Report the name of the Plan Sponsor.
2. Business Code – Report the six-digit code that best describes the nature of the employer’s business.  If more than one employer is involved, report the business code for the predominant business activity of all employers. A list of business codes can be found in the instructions to Form 5500 and in the "Premium Filings" section of the Practitioners Page on PBGC’s website.   Because codes for the Premium Payment Year may not be available at the time you submit this filing, you may report the relevant code for either the Premium Payment Year or the prior year. 
3. CUSIP number – If a CUSIP number has been assigned to publicly traded securities of the Plan Sponsor or any member of the Plan Sponsor’s controlled group, report the first six digits of the CUSIP number. Otherwise, leave this item blank.

   A CUSIP number is a nine-digit number assigned to the publicly traded securities of a Plan Sponsor (or member of the Plan Sponsor’s controlled group) under the securities numbering system of the Committee on Uniform Securities Identification Procedures. The first six digits of the CUSIP number identify the securities issuer, the next two digits identify the specific securities issue, and the last digit is a check digit.

2 Plan administrator information

a-g Report the name and address of the Plan Administrator. Note that this is the address where we send official correspondence to the plan (e.g., an invoice for late payment charges).

h Report the name, e-mail address, and phone number of the person we should contact if we have any questions concerning this filing. We will send official correspondence to the "attention of" this person at the address reported in (b)-(g). In addition, unless a different phone number is provided in item 2i, the phone number reported in 2h will be posted on PBGC’s Is my Pension Insured list as the number plan participants should call if they have questions about their plan.

i If you would prefer plan participants with questions about their plan call a phone number other than the one reported in item 2h, report the phone number you would like them to use. If this item is left blank, the Insured Plans List on PBGC’s website will show the phone number reported in item 2h.

To keep our records current and enable us to send correspondence to the correct address, you should inform us of address changes as soon as they occur. You may do so by contacting us either in writing or by e‑mail. See Appendix 2 for contact information.

3 Additional plan contact (optional)

Although official correspondence related to premium filings is directed to the Plan Administrator (see item 2), some plans choose to provide contact information for another individual as well. In general, the contact person identified in this section will be used for questions that aren’t important enough for official correspondence. PBGC may also contact this individual if official inquiries to the Plan Administrator go unanswered.

4 Plan information

1. Plan name – Report the complete name of the plan as stated in the plan document. For example, "The ABC Company Pension Plan for Salaried Personnel."
2. Premium Payment Year information

   (1) Report the date the Premium Payment Year commences and the date it ends. If you are filing for the first year of a New Plan, the Premium Payment Year commencement date ("PYC") should be the plan effective date.

   (2) Check the appropriate box to indicate whether the plan is a Small Plan for the Premium Payment Year (See definition of Small Plan in Appendix 1).

   (3) If the plan year commencement date has changed since the most recent PBGC filing as a result of a plan amendment changing the plan year, enter the adoption date of the plan year change.

   (4) Check the box if plan qualifies to pay a prorated premium for this Premium Payment Year. A plan qualifies to pay a prorated premium if the Premium Payment Year is:

   • is a short first year of a New Plan;
   • is a short year created by:

     - an amendment that changes the plan year (but note that an amendment is not considered to change the plan year if the plan merges into or consolidates with another plan or otherwise ceases its independent existence either during the short plan year or at the beginning of the full plan year following the short plan year);

     - distribution of plan assets pursuant to plan termination; or

     - the appointment of a trustee for a Single-employer Plan under ERISA section 4042.

   • Includes a portion of time in which the plan was not covered by PBGC, unless such period of non-coverage began after the first day of the plan year.

     Note that the short year need not have ended by the time you pay a prorated premium, but if the plan year turns out to be longer than you anticipated, you will have to make up any premium underpayment, which will be subject to interest and penalties.

     Note also that premium proration is not available for "overlapping" premium payments resulting from a plan Merger, Consolidation, or Spinoff.

3. Employer Identification Number (EIN) and Plan Number (PN) information

   (1) Report the nine-digit EIN of the Plan Sponsor and the three-digit PN of the plan.

   (2) If the EIN and PN for this filing do not both match exactly the EIN and PN reported in the most recent premium filing, report both the EIN and PN that were reported in the most recent premium filing. If this is the first premium filing for this plan, leave this item blank.

   Please note the following exceptions that apply only if this is an amended filing:

   • If item 4c(2) was reported incorrectly in the original filing (i.e., the filing that is being amended), provide the correct information in the amended filing.
   • If item 4c(2) was reported correctly in the original filing, provide the same information in the amended filing.

     (3) If the EIN and PN for this filing do not both match exactly the EIN and PN reported in the 2015 Form 5500, report both the EIN and PN that were reported in the 2015 Form 5500, and attach an explanation. If a 2015 Form 5500 was not required, leave this item blank.

4. Plan effective date – Report the date the plan became effective.
5. Plan type – Indicate whether the plan is a Multiemployer Plan or a Single-employer Plan.
6. Information for New or Newly Covered Plans – If this is a New or Newly Covered Plan, check the box and complete the rest of item 4f.

   (1) Adoption date – Enter the date the plan was adopted

   (2) Coverage date – Enter the date the plan became covered under Title IV. If the plan has had one or more periods of coverage, report the earliest date in the Premium Payment Year when the plan was covered under Title IV — not the date when the plan became covered in a prior year. If another plan transferred assets or liabilities to this New or Newly Covered Plan, be sure to complete the "Transfers from other plans" item (see item 14).

   (3) Continuation Plan – Check the box to indicate whether this New or Newly Covered Plan meets the definition of a Continuation Plan (see definition).