Pension Or Premium Finance Proposal

To request a proposal, please enter your business' information below, followed by an employee census.
After completing these forms, please select "Submit Proposal Request" at the bottom of this page.

Proposal Request Type:
Producer Name:
Producer Phone:
Producer Email:
Client Name:
Client Phone:
Client Email:
Date Of Birth:
State:
Gender:
Smoker:
Health:
Requested Death Benefit:
Preferred Premium:
Net Worth:
Liquid Net Worth:
Annual Income:
Enter Pertinent Policy Design Specifics or Case Specifics:	Please Include Pertinent Policy Design Specifics or Case Specifics

Business Information

Producer Client

Name of Business:

Tax Status:

Financial Professional:

Client Name:

Phone:

Email:

Date Business Began:

Date Of Incorporation:

Tax Year End:

State of Domiclie:

Approximate Contribution Desired:

% $ Maximum
(percent of pay or dollar amount)

Any current pension plan in force?

If so, please supply details:

Yes No Other:

(401(k), Defined Benefit, etc.)

IMPORTANT:
Do the owners have
ownership interests in
any other firms?

If so, please supply details:

Yes No

Please Indicate Ownership Interests Here

Details and Comments:

Employee Census

Please enter the information below for each of your employees.
Space is available for up to twenty employees.
At least one employee must be listed below.

First Name	Last Name	% Stock Owned	W 2 Compensation	Schedule C -or- K 1 Income	Annual Hours Worked (if part time)
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
*Part-time is defined as working less than 1000 hours during a twelve month period. Add More
First Name	Last Name	% Stock Owned	W 2 Compensation	Schedule C -or- K 1 Income	Annual Hours Worked (if part time)
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
*Part-time is defined as working less than 1000 hours during a twelve month period. Add More
First Name	Last Name	% Stock Owned	W 2 Compensation	Schedule C -or- K 1 Income	Annual Hours Worked (if part time)
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
*Part-time is defined as working less than 1000 hours during a twelve month period. Add More
First Name	Last Name	% Stock Owned	W 2 Compensation	Schedule C -or- K 1 Income	Annual Hours Worked (if part time)
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
*Part-time is defined as working less than 1000 hours during a twelve month period. Add More
First Name	Last Name	% Stock Owned	W 2 Compensation	Schedule C -or- K 1 Income	Annual Hours Worked (if part time)
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?
		%	$	$
Birth Date: / / Hire Date: / / Family Member of Owner?