Company Name

Address            

Address 2         

Business Type (C-Corp, S-Corp, etc..)  

State of Incorporation   Alabama Alaska Arizona Arkansas California Colorado Connecticut Delaware Florida Georgia Hawaii Idaho Illinois Indiana Iowa Kansas Kentucky Louisiana Maine Maryland Massachusetts Michigan Minnesota Mississippi Missouri Montana Nebraska Nevada New Hampshire New Jersey New Mexico New York North Carolina North Dakota Ohio Oklahoma Oregon Pennsylvania Rhode Island South Carolina South Dakota Tennessee Texas Utah Vermont Virginia Washington Washington D.C. West Virginia Wisconsin Wyoming

Fiscal Year  

Number of Eligible Employees  

Current Provider  

Number of Participants  

Current TPA (5500Filings)  

Recordkeeping (Source of Statements)  

Do you offer a ROTH option? Yes No

Do you get regular local reviews Yes No

Are you/employees happy with your investment chioces? Yes No

Are you/employees happy with the investment company service? Yes No

Contributions will come from employer

Employer set amount

Employer Profit Share

Employer Bonus

Poor investment performance Yes No

Poor plan service Yes No

Poor broker service Yes No

Name of Contact Person  

Contact Phone Number  

Contact E-mail  

General concerns or questions?

     

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