Employer General Information:

Company Name: Address: City, State, Zip: Employer's Taxpayer Identification Number: Business Code: Fiscal Year:

Type of Entity:

1. Corporation (including Tax-exempt or Non-profit Corporation)
2. Professional Service Corporation
3. S Corporation
4. Limited Liability Company that is taxed as:
1. A Partnership or Sole Proprietorship
   
2. A Corporation
   
3. A S Corporation
   
5. Sole Proprietorship
   
6. Partnership (including Limited Liability)
   
7. Other:
   

Owner(s) Information:

Name Title % of Ownership

Enter name(s) or all family members who are employed at the company and relationship to the owner(s) below:

Name Related to Relationship

List any other businesses owned:
Any former retirement plan? If so, type of plan and termination year:
Total number of current employees, including yourself:
Total number of leased employees, if any:
Total number of employees whose retirement benefit is covered by a collective bargaining agreement:
Name of contact person and title (person who will get all our correspondence):
Email address for contact person:
Email address that you want ALL confidential plan information sent to (home or office):

Payroll Information:

Name of payroll service:
Payroll contact name:
Payroll contact phone number:
Payroll contact email address:

Payroll Frequency (check all that apply):
Weekly Bi-weekly Bi-monthly Monthly

Do you run multiple payroll reports: Yes No

Tax Accountant Information Name: Firm: Address: Phone/Fax: Email Address:

Financial Advisor Information (if you currently have one) Name: Firm: Address: Phone/Fax: Email Address:

Who will be the trustees on this account?

Name Title

Or are you planning on having an outside trustee?

Yes No

Anything else you think we should know: