Request for Proposal

Please complete the following request form to receive FREE information and a proposal on a Qualified Pension Plan. Please note: All fields must be completed.

  City:         State/Province: 
  Zip Code:   
  Work Phone: 
  Your Position: 
  Which item(s) best describe your reason for the inquiry:

  Name of Business:   
  Nature of Business: 

  Business tax year end (MM/DD): 
  Number of eligible employees:  

  Type of legal business structure:

  Is the business associated with any other business by common ownership 
  or by maintaining an affiliate service group?
     Yes    No

  Is there a union with which retirement benefits have been the subject of 
  good faith?
     Yes    No

  If yes, will bargaining employees be included in the plan?
     Yes    No

  Who does the payroll processing?
  Please indicate desired investment:

  Who will make the investment choices?

  The business' estimated desired payroll contribution for the first year
  Does the business wish to commit to a fixed contribution every year?
     Yes    No

  Desired plan type:


If You Have an Existing PLan

  What was the plan's effective date:   Years Established: 
  Number of participants:               Approx. Value: 
  Annual contribution flow:             
  Approx. Annual Charges:             

  Frequency of values provided:
  Is the business dissatisfied with the administration and/or investments
  of the plan(s)?  Please explain:

  Your time frame to establish such a plan is?
     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.