Split-Dollar Life Insurance Arrangement

Report your arrangement for coverage by a split-dollar life insurance policy in Part 3.  In addition, report the policy coverage in Part 2 (see Part 2 of this guide for details).

Employer or Party


Status and Terms


SendNow Co.

Fort Wayne, IN

After my separation, the firm will continue paying the premiums for my split-dollar variable life policy, which the firm will recover from the death benefit.


For You

Part 3

Report your continued participation in a split-dollar life insurance policy arrangement.  In addition, if you are an Annual or Termination filer, report a split-dollar life insurance policy arrangement in which you participated at any point during the reporting period.

Employer or Party:  Provide the name of the employer.

City/State:  Provide the city and state in which the employer is located.

Status and Terms:  Identify the arrangement as a split-dollar life insurance policy and indicate whether you will continue to be covered by the policy.  If you will continue to participate, specify whether the employer will continue to make contributions.  You do not need to specify how the premiums will be repaid, but providing this information is helpful.

Date:  Provide the month and year in which your coverage began.