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Your Information
Producer’s Name*
Broker Dealer/RIA*
Business Name*
Mailing Address*
City*
State*
Zip*
Business Phone*
Mobile Phone
Email*
Confirm Email*

Desired Compensation
Call Me to Discuss Options
 		 Yes No
 
Client/Prospect Information
Legal Name of Business*
Client Mailing Address*
Client City*
Client State*
Client Zip*
Client Phone*
 
Entity Taxed as*		  
 
Is Business a Non-Profit		  
Yes No             If Yes, what Code Section
   
Name of Principal Title % Ownership
Name of Principal Title % Ownership
Name of Principal Title % Ownership
Name of Principal Title % Ownership
 
Does any of the above Principal(s) own all or part of another Business?*
If yes please list the names of the business(es), owner(s), and the percentage(s) of ownership:
 
Does the employer currently have a Qualified Retirement Plan, SEP, or Simple IRA Yes No
If yes Please Describe
 
Plan Information
New Plan
          Estimated amount of annual recurring contributions
          Approximate Number of Employees
Takeover
          Required for Takeover Proposal:
          Adoption Agreement and/or Summary Plan Description
          Current Plan Enrollment Form
          Estimated existing plan assets available for transfer
          Estimated amount of annual recurring contributions
 
          Are there any current surrender charges? If yes %
 
          Approximate Number of Participants with an Account Balance
          Approximate Number of Employees
 
Desired features*		  
Private Money Manager
Trust Services
Personal Brokerage Accounts
 Target Retirement Funds
Lifestyle Retirement Funds
Other
Other Describe
 
Proposals Needed by		  
Client Copies
Advisor Copies
If Needed Overnight:
          Carrier		  
          Account Number
Additional Comments

 
 
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