Dynamic Pension Services

QUOTE FOR SERVICES WORKSHEET
* = Required Field

1) Company Information

Submitted By: *
Submitter's E-Mail: *
Company:*
Address 1: *
Address2:
City/State/Zip: *
Contact Phone: *

Business Type: *
Plan Type (Select all that apply): *	401(k) 403(b) MT PS MP
Number of eligible employees: *

2) Broker Information:

Contact Name:
Company:
Address1:
Address2:
City/State/Zip:
Phone #:
Fax:
E-Mail:

3) FOR NEW CASES ONLY (Note: Section 3 or Section 4 must be completed)
    A) New funding vehicle to be used:
    B) Product Type:
        Allocated/Individual Accts. Unallocated/Pooled Accts.

4) FOR TAKEOVER CASES ONLY (Note: Only complete this section if you did not complete the "For New Cases Only" section above. Otherwise, skip to section 5.)
    A) Where are the present assets?:
    B) Where will the assets be transferring to (if applicable)?:

    C) Product Type:
         Allocated/Individual Accts.   Unallocated/Pooled Accts.

5) Does the plan or will the plan have a loan provision and/or hardship provision as an available form of benefit?
Loans? * Yes No Hardships? * Yes No

6) Where should the proposal be sent?  (select one of the following):
    Company's Mailing Address (provided in Section 1) or
    Company Fax: or
    Company E-Mail:

OR

   Broker's Mailing Address or
    Broker Fax or
    Broker E-Mail
        (if selected, please ensure that the e-mail address is entered in Section 2)

After submitting the request for quote, you will receive a response from Dynamic Pension within 24 hours.