Name:         
  Address:    
  City:         State/Province: 
  Zip Code:   
  Email:      
  Work Phone: 
  Fax:          
  
  Your Position: 
  
  
  Which item(s) best describe your reason for the inquiry:
    New PlanTake over of an existing planChange in company structureIn need of new AdministratorDissatisfied with level of serviceDissatisfied with investment optionsJust shopping

  Name of Business:   
  Nature of Business: 

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

  Type of legal business structure:
    C CorporationPartnershipSub-S CorporationNon-profit/501 (c) (3)ProprietorshipProfessional Corporation
    Other: 

  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?
     Employer
    Other: 
  
  Please indicate desired investment:
    Mutual FundsFixed, Guaranteed AccountsIndividual Annuity ContractsUnsure, Want to Discuss

  Who will make the investment choices?
    The employer (or trustee)Each plan participantOtherUnsure, want to discuss

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

  Desired plan type:
    Profit sharing401K profit sharingAge-weighted profit sharing403 (b) TSAMoney PurchaseSimplified employee pensionSIMPLE PlanTarget benefitUnsure, want to discuss

  

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

  Frequency of values provided:
    DailyMonthlyQuarterlySemi-AnnuallyAnnually
  
  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:
    NoneLowMediumHighVery High 

  Are you a Financial Advisor? (RIA, stockbroker, insurance agent, fee planner):
    NoYes
  

  Additional Comments/Questions: