Census Information: The information requested below will assist us in preparing a pension proposal for your Company.  Your assistance is greatly appreciated and we look forward to being of service. It may be necessary for us to contact you regarding additional information, once we review the the forms below in order to present an accurate quote based on your goals and funding of the plan. You may complete the form here and email it to us, or download to a printer and fax or mail to our office. Sincerely, John A. Beyer, CLU

Name:
Title:
Company Name:
Company Size:
Industry Type:
SIC Code:
Address:
City:
State:
Zip:
Phone:
Fax:
Email:
Number of Covered Employees:
Do you have a current pension plan?	Yes No
If yes, carrier & effective date of plan:
Type(s) of pension plan:
Requested pension plan: (Multiple selections allowed)	401k	401k simple	IRA simple
	401k w/ comparability		IRA
Additional coverage would like with new plan:
Preferred employer match:	0% 25% 50% 100%
Percent of employee salary for match:	3% 4% 5% 6%
Number of years in business:
Additional requirements:
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Number of Employees:

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