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If more than 5, how many employees do you want to list?

This quote is for:*

412 (i) Plan
Traditional 401 (k) Plan
Simple 401 (k) Plan
Simple IRA Plan
Money Purchase Pension Plan
Profit Sharing Plan
Defined Benefit Plan

Agent / Broker Full Name:*

First Last

Company Name:

Company Address:

Street Address Address Line 2 City State / Province / Region ZIP / Postal Code Country

Your E-mail Address:*

Phone Number:*

Your Fax Number:

Client Company Name:

State client located in:*

Tax Status*

Tax Year Ends (MM/YYYY):

Do the Owners of this Company have any Ownership Interest in any other Business or Firm?*

Yes
No

When was this Company started, or date of incorporation?*

When was this company founded or started? (MM/DD/YYYY):*

Does the company currently have plan(s)? (qualified or non-qualified)*

Yes
No

If so, please indicate what type of plan and give a brief description including; who participates in the plan, total plan asset value, current investment and current contribution (% or $ amount):

Approximate desired Contribution Dollar Amount, or % of Income:*

Accountant's Name

First Last

#	Emp. Initials	Gender	Related to Owner	Employee DOB (MM/DD/YYYY)	Annual Earnings (including overtime & bonuses)	Date of Hire (MM/DD/YYYY)	Full or Part Time

Accountant's Phone

Any Additional Remarks, Plan Design Requests, Specific Companies to Quote, etc.?

How would you like to receive the requested information?*

Email
Fax
Pick-Up

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Pension 412(E) Quote

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