Campbell & Associates Insurance, Inc.

If you are requesting a quote, it 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 quote purposes only. If you prefer, you may contact us directly. We look forward to serving you.


Contact Information

City:  State:    
Work Phone Number :
Home Phone Number :
Fax Number :
Email Address:

Additional Information

How Soon Do You Want to Implement a New 401k Plan?: ASAP
Within two weeks
Within one month
Within two months
More than two months
Do You Currently Offer a 401k 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: Less than 5
Type of Investment Vehicle: (check all that apply) Multiple Mutual Funds in a Single Fund Family
No-Load Mutual Fund
Self-Directed Brokerage Account
Not Sure
Number of Investment Choices You Would Like the Plan to Offer: 1-3
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.

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