1. Date                    Date Proposal Needed

2. Broker Name       Broker Firm                  

3. Broker Address to send proposal:

4. Broker Phone Number:  Fax Number: 

    E-mail         

5. Company Name of Prospect

6. Type of Plan: (choose one)

401(K) Plan with Pro Rata or Integrated Formula

Cross Tested Plan (either 401(k) or Profit Sharing) – census required for illustration

Profit Sharing Plan

Money Purchase Plan

7. Conversion Plan/New Plan 

Conversion Plan

New Plan

8.If conversion plan, who is the current Third Party Administrator?    

9.Is the current document a nonstandardized/standardized prototype?

 10. Are the assets currently pooled or daily valued by money type? (ie employee money segregated from employer money by participant) 

11.Who currently holds the plan assets if conversion plan? 

12.Fund Family/Families for the proposal?   

13.Approximate Number of Participants?

Eligible        Total Number of Employees

14. Approximate Assets if conversion plan   

15.  Special considerations/notes:

16.  Illustration requested? Yes/No.    Please click here to download census spreadsheet to be completed if an illustration is needed. 

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