• Previous 3 years of corporate tax returns

• YTD P&L (CPA generated if possible)

To change number of plans, go to previous page (Practice B) and adjust number of plans.

Preferred Provider Plans

% of Normal Fee

Capitation Plans

% of Normal Fee

Major Employers in the area:

Please use this section to list all direct employees and contractors. Do not include contracted services (such as janitorial, maintenance, equipment and tool cleaning services, etc).

Please click the ㊉ symbol to add row.

Please click the ㊉ symbol to add row.

Annual Insurance Expense

Annual Tax Expense

Total Annual Pension Expense