Qualified Plan Administrators, Inc.

"Your retirement plan specialists"

In order to provide you with the most accurate quote possible, we need for you to complete the following information request.  This will provide QPA with details concerning your current plan, as well as your company.

Please provide any additional comments that would better enable us to understand your plan needs or concerns.  If this request is urgent, you may prefer to contact Karen Dixon or Jim Redmond by telephone at 1-888-607-5600 (888-401kinc).

Prefix:                                                        Mr.    Mrs. Ms.    Dr.

First Name:                                                          

Last Name:                                                       

Title:                                                           

Telephone Number:                                     ( )   ext

Email Address:                                                  (required)

Company/Organization Name:                       

Address (Street):                                         

Address (Street) 2:                                      

State:                                                         

Postal Code:                                                

Type of organization:                                      For Profit              Not for Profit

Existing Plan:                                                 Yes                      No

Type of Plan:                                                  

Plan's Original Effective Date:                         

Current Plan Asset Value:                                

Number of Employees:                                    

Types of Contributions (all that apply):             Employee Deferrals          Employer Matching   

                                                                   Employer Discretionary       Employer Safe Harbor               

Services Desired (check one):                          Daily Recordkeeping and Quarterly Administration

                                                                     Daily Recordkeeping and Annual Administration

                                                                     Quarterly Recordkeeping and Quarterly Administration

                                                                     Daily Recordkeeping Only

                                                                     Annual Administration Only

Comments:                                                 

Once you have completed this form, please print it and fax it to 706-722-1208 to the attention of Karen Dixon.

                                                                                            07/23/2004