162 Executive Benefit Plan Request Form

Please complete the following request form to receive FREE information on Section 162 Executive Bonus Plans. Please note: All fields must be completed.

  City:         State/Province: 
  Zip Code:   
  Home Phone:   
  Work Phone: 
  Employee's Name: 

  Employee's Date of Birth: 
     Yes    No   
  Employee's tax bracket is:
     28%    31%    36%    39.6%    Unknown
  Bonus/Payment Amount:                
  Expected Number of Bonuses/Payments: 

  Employee's Position: 
  What is the possible time frame for implementing such a program?
     Less than one month    1 to 3 months    3 to 6 months
  Your general awareness on this subject is:
  Are you a Financial Advisor? (RIA, stockbroker, insurance agent, fee planner):

  Additional Comments/Questions:


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All Rights Reserved.

Securities offered through Fortune Financial Services, Inc. member FINRA, SIPC.  Fielder Financial Management, Ltd. not affiliated with Fortune Financial Services, Inc.  Mark Fielder, Financial Professional, CA. Insurance Lic. # 0690576.