| Representative/Agent/Broker: |
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| Date: |
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| Address: |
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| City: |
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| State: |
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| Zip Code |
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| Phone: |
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| Fax: |
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| Email: |
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| Contact: |
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| Type of Business: |
C-Corp
S-Corp
Partnership
Non-Profit
PC
LLC
Other: |
| Number of Employees: |
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| Anticipated Number of Employees in 12 months: |
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| Will this be a New Plan or a Takeover Plan? |
New Plan
Takeover Plan |
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| NEW PLAN |
| If a New Plan, what type of Plan is it? |
401(k) Profit Sharing
Profit Sharing Only
Other: |
| Does employer currently maintain, or ever maintained, another qualified retirement plan? |
Yes No |
| If so, please provide additional information: |
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| Plan Type: |
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| # of Participants: |
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| Provider: |
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| TAKEOVER PLAN
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| If a Takeover Plan, what type of Plan is it? |
401(k) Profit Sharing
Profit Sharing Only
Other: |
| Does owner own any additional employer entities? |
Yes No |
| Which company administers the existing plan? |
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| Current amount of assets in the existing plan: |
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| Annual flow of Money into the Plan: |
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| ***** If plan is Takeover, please attach: |
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| (1) Current Plan document: |
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| (2) Most recent Plan Valuation from current administrator |
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| (3) A recent investment account statement, reflecting all plan investments: |
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| List venders/platforms to be presented with this proposal: |
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| Complete Census: |
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| DATE PROPOSAL TO BE PRESENTED: |
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| DATE PROPOSAL NEEDED: |
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