Representative/Agent/Broker:
Date:
Address:
City:
State:
Zip Code
Phone:
Fax:
Email:
Contact:
Type of Business:
Number of Employees:
Anticipated Number of Employees in 12 months:
Will this be a New Plan or a Takeover Plan?
NEW PLAN
If a New Plan, what type of Plan is it?
Does employer currently maintain, or ever maintained, another qualified retirement plan?
If so, please provide additional information:
Plan Type:
# of Participants:
Provider:
TAKEOVER PLAN
If a Takeover Plan, what type of Plan is it?
Does owner own any additional employer entities?
Which company administers the existing plan?
Current amount of assets in the existing plan:
Annual flow of Money into the Plan:
***** If plan is Takeover, please attach:
(1) Current Plan document:
(2) Most recent Plan Valuation from current administrator
(3) A recent investment account statement, reflecting all plan investments:
List venders/platforms to be presented with this proposal:
Complete Census:
DATE PROPOSAL TO BE PRESENTED:
DATE PROPOSAL NEEDED: