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Census Questionnaire

Our Census Questionnaire is available online – on a secure connection – for your convenience. You can easily fill out the form below. However, if you are more comfortable with downloading the Census Questionnaire in PDF format and submitting by fax, please feel free do so by clicking here. Our fax number is 407-875-0189.

    Plan Sponsor Name

    Plan Year End

    If this Plan covers employees of more than one company, please give the data for each company.

    Names of Officers or Partners Who are Employees

    Titles

    Names of Stockholders/Partners Who are Employees

    % of Stock/Partnership interest owned

    Are there other businesses, incorporated or not, owned by this business or the owners of this business? Is this an affiliated service group?
    YesNo

    Please list the names of any employees who are related to stockholders.

    Name

    Relationship

    Related to Whom

    Fiduciary Surety Bonding Information

    Name of Insurance Company

    Amount of Bond

    Did you, or a business you control, maintain any other qualified plan (including frozen plans) for which Pension Investors Corp. does not provide services?
    YesNo
    If Yes, explain:

    Are there shared or leased employees?
    YesNo

    Completed By

    Title

    Date Completed