Section 13, Part B - Life Insurance - Detailed Questions
Section 13, Part B collects detailed information about life insurance policies reported in Part A.1.
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What is the name of the insurance company for "your (1st, 2nd, 3rd)"
life/disability policy listed? [enter text] __________________
Briefly describe the policy. [enter text] ______________
Are the policy premiums paid -
2. Partially by you or your household and partially by someone outside your household?
3. Entirely by an employer or union?
4. Entirely by another group or persons outside your household?
Are any premiums paid through payroll deductions?
Since the first of the reference month, what was your or your household total expense for this insurance policy? [enter value] ______________
* Enter the actual amount the household paid. Do not include any expenses paid for the household by others
How much was paid this month? [enter value] ______________
End of Section 13B Life Insurance
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Last Modified Date: April 3, 2013