• Your Name:  

    • Your State:  

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    • Your Email:

    • Your Phone:

    • Your Fax:

Employer Information

  • Company Name:

  • Company Address:

  • Date Business Started:

  • Business Entity:

C Corp; S Corp; Sole Proprietor; Partnership; Professional Corp; Government/457; 501(c)(3); LLC; other:

  • Number of Full Time Employees (1000 Hours or More):   

  • Number of  Part Time Employees (Less than 1000 Hours):

  • If the business uses the services of leased employees, how many?

  • Do the leased employees have a retirement plan sponsored by the leasing

    company? Yes  No

  • Are any employees subject to a Collectively Bargained Agreement?Yes No

  • If the owners of this company (or owner's spouses or minor children) have ownership in other companies, please describe:

  • Any existing coverage (if life insurance, provide current annual premium, death benefit, cash surrender value, and projected cash surrender value at age 65):

Plan Objectives

Desired Employer Contribution

Dollar Amount:     

or

Expressed as a % of Payroll: %