Client Contact:

*Company Name:

Address:

*City:

*State:

Zip Code:

Phone:

Fax:

*Email:

Number of Entities:

Type of Entity:

If C-Corp, is company publicly held?

If publicly traded, please list exchange:

If publicly traded, please list trading symbol:

Centralized Payroll:

If not centralized payroll, please explain:

*Number of Employees:

*Eligible Employees:

*Participants:

Full Name:

Title:

Firm:

Address:

City:

State:

Zip Code:

Phone:

Fax:

Email:

Current TPA

Value of Current Assets ($)

Current Plan Year End:

COMMENTS
Please provide details regarding any special situation that may have a bearing on this quote. Also, if you would like additional proposals with specific variations, please list them below.