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Company Retirement Plan

The information you have requested requires that you complete the following survey as completely and accurately as possible. Once submitted the information will be e-mailed to our office(s) and we will expedite your request. This information will be kept confidential and will be used for internal purposes only. We look forward to serving you.

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Contact Information

* Name:

Address:

City:

State: Zip:

Phone:

* Work:

* Home:

* Cell:

Fax:

* Email Address:

*Best date and time to be reached in the next 48 hours.

Date:		/
	MM	/	DD

Time:

What type of plan are you looking to implement?

401 (k)
SEP IRA
Simple IRA
Other
Unsure

Additional Information
How Soon Do You Want to Implement a New Plan?:	ASAP Within one month Within the next quarter More than three months
Do You Currently Offer a Retirement Plan?:	No Yes If 'Yes', Approximately How Much Do You Plan to Rollover Into the New Plan? If 'Yes', What Is the Approximate Amount of the Annual Contributions to Your Current Plan? (include employee plus employer contributions - excluding company stock)
Number of Eligible Employees:
Number of Employees Likely to Participate in the Plan:
Number of Domestic Locations/Offices Your Business Maintains:	1 2-5 More than 5 100+
Number of Investment Choices You Would Like the Plan to Offer:	1-5 5-20 20-50 More than 50
Will You Be Matching Any Portion of the Employee's Contribution?:	No, We Will Not Be Matching At This Time Yes, We Will Be Matching Based on Profitability Yes, We Will Specify the Percentage Amount

Additional Considerations/Requests

Please give any additional comments you feel appropriate for this quotation such as mutual fund families you would like to offer.

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Dominion Financial Group, Inc.
5520 Wellesley St., Suite 203
La Mesa, CA 91942
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(619) 644-3545 – Office
(619) 644-3550 – Fax

Securities offered by a Registered Representative of Sammons Securities Company, LLC. Member FINRA / SIPC.

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Company Retirement Plan

Contact Information

Additional Information

Additional Considerations/Requests