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Do you have a plan? Is it working for you?

By filling out and submitting the form below, we will be able to create a set of recommendations that you can use to implement an efficient and productive retirement plan - one that creates immediate tax savings for your business, and provides future benefits to you and your employees.

Please note, the census is only a preliminary fact finding tool. Further information will be required for a qualified plan analysis.

All information will be kept strictly confidential.
Contact name:  
Address:  
City:  
State:  
Zip:  
 
Telephone:  
Fax:  
Email:  
 
Current Plan:  
 Profit Sharing
Defined Contribution
Defined Benefit
No plan in place
Business type:  
 Corporate
Non-Corporate
Business name:  
Desired Budget Amount:  

ee family,
share-
holder,
owner?		 favored? dob
mm/dd/yyyy		 date of
employment
mm/dd/yyyy		 total w-2 compensation % of business owned annual hours > 1,000?
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One National Life Drive, Montpelier, Vermont 05604, Telephone: 800-536-5934
  EXPLANATION OF FORM FIELDS FOUND ABOVE


  

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FAMILY, SHAREHOLDER, OWNER?
Indicate that this employee is a family member of the owner(s), a shareholder in the company, or an owner of the company by checking the box as appropriate.


  

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FAVORED?
Check the box for those employees who you wish to favor in the plan analysis.


  

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DOB MM/DD/YYYY
Please specify the date of birth for each employee using the month/day/year format.


  

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DATE OF EMPLOYMENT MM/DD/YYYY
Please specify the date of employment for each employee using the month/day/year format.


  

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TOTAL W-2 COMPENSATION
Fill in the total compensation as it would appear on the IRS Form W-2, box nn.


  

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% OF BUSINESS OWNED
If this employee is also an owner, indicate the percentage of ownership in whole numbers - i. e. 25%


  

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ANNUAL HOURS > 1,000?
If the employee works more that 1,000 hours annually, please check the box as appropriate.