Plan In A Box - Retirement Plan Application

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Enter financial representative information

Advisor or Representative Name

Company

Street Address

City

State

Zip Code

Telephone

Fax

Agent ID#

Did you complete the required
HMU Training & Assessment course -
"Basics of 401(k) Plans and Plan In a Box Program"?

Yes
No

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Enter Plan Sponsor Information

Company

Street Address

City

State

Zip

Company Contact

Telephone

Fax

Fiscal Year End

Company EIN

Nature of Business

Type of organization

Define Ownership

Name Ownership %

Ownership 2 Name Ownership 2 % Ownership 3 Name Ownership 3 Percent % Ownership 4 Name Ownership 4 Percent %

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Plan Information

Is this a new plan or a takeover of an existing plan?

New Plan
Takeover

Name of person(s) serving as plan trustee

Name

Number of Participants

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Authorization & Signature

Annual Fee Payment Structure (Deducted on a Quarterly Basis)

$950 (Employer Paid on 10th day of 3rd, 6th, 9th, 12th month)
$30 Per Participant (Deducted from Participant Account)
.50% (Paid by Plan Assets Pro Rata)
.03% for SWBC (Paid by Plan Assets Pro Rata)
Exclusive Agent Service Fee:
<$1MM = 1.00% (Paid by Plan Assets Pro Rata)
>$1MM = .75%

Authorization For Direct Payment

I authorize the Benefit Consultants Group and the financial institution named to initiate entries in my checking account for the component of the plan administration fees that are the responsibility of the employer. This authority will remain in effect until I notify you in writing to cancel it in such time as to afford the financial institution a reasonable opportunity to act on it. I can stop payment of any entry by notifying my financial institution three days before my account is charged.

Plan Trustee Name

Date

Company Name

Street Address

City

State

Zip Code

Bank Name

Branch

Checking Account Number

Bank Routing Number
(located on the bottom of your check - 9 digits)

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Enter financial representative information

Enter Plan Sponsor Information

Plan Information

Name of person(s) serving as plan trustee

Authorization & Signature

Annual Fee Payment Structure (Deducted on a Quarterly Basis)

Authorization For Direct Payment

Certification & Signature

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