Proposal Request
Please provide the following employer information
(*Indicates a required field)

Company Contact:
Company Name:*
Company Address:
Address (cont.)
City:*
State/Province:*
Zip/Postal Code:
Phone:* Ext.
FAX:
E-mail:*

Company Business Information
Description of Business:*
Date of Registration:
(MM/DD/YY)
State of Registration:
Tax Identification #:
Fiscal Year End:*
(MM/DD/YY)
Shareholder Information:
List of Officers, Directors and Stockholders of the Company (name and percentatge)
Full Name:* %:*

Company Accountant Information:
First Name:
Last Name:
Phone:
Email:

Company Attorney Information:
First Name:
Last Name:
Phone:
Email:


Contribution Information:

Do employer owners own other businesses with 50% ownership?*

Yes No

Desired retirement age?:*

Desired first year contribution?:

Desired number of contribution years?:

Average employee tenure years:

Existing Benefit Plans:

Existing Benefit, Pension or Profit Sharing Plan*

 Yes No
If "Yes", what type:
If "Yes", what is the normal annual contribution? (Dollar Amount):

Employer Proposal Census Data:
Last
Name *
First
Name *
DOB *
(MM/DD/YY)
Sex
M/F *
Date of Hire *
(04/04/99)
W2 Compensation*
Schedule C
Or K1 Income *
Smoke (Y/N) *
1000 hrs/yr (Y/N)*
Related to owner (Y/N) *
Percent of Stock
(%) *
Union (Y/N)*
1
2
3
4
5
6
7
8
9
10

Proposal requested by:
First Name:*
Last Name:*
Organization:*
Street Address:*
Address (cont.):
City:*
State Province:*
Zip/Postal Code:*
Country:*
Phone:*
Fax:*
Email:*
Proposal needed by (date)*

Professional Affiliation:
Professional
Agent:
Company:
Other:
Comments:

Would you like this information to be entered for a 412(i) plan as well?
Yes No
Above information may be relied on by Plan Administrator for plan design and administration.
Employer Signature:*
Date:* (MM/DD/YY)






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