
Full Name		Zip
Company		Address
Phone		City
Email		State
Best way to contact you		Best time to contact


Current 401k Provider?
Approximate total assets in current 401k plan?
Approximate monthly contributions?
What percentage of matching (percent or dollar amount) is the company currently providing to the participants?
What do you like or dislike about the current plan offered?
If you do not currently offer a 401k plan, what specific benefits are you looking for?

401(k) Plan Information
When would you plan on implementing your new 401(k) plan?		During the next month Within three months Before the end of the year
How many employees would be eligible for the 401(k) plan?
What percentage of eligible employees would you expect to participate?

Investment Options
What types of investment vehicles would you like to offer eligible employees?		Mutual Funds Self-Directed Brokerage Account Need more information to decide
Do you plan on matching any portion of the employee contribution?		Yes No

Please note any special features or options you would like to offer as part of your new 401(k) plan.

Securities and Advisory Services offered through Hornor, Townsend & Kent, INC. (HTK), Member FINRA/SIPC, Registered Investment Advisor 1475 S. State College Blvd., Suite 114, Anaheim, CA 92806