401(k) Enrollment Form

Fill this form out to enroll, make changes to the amount you contribute to the 401(k), or update your beneficiaries.

Employer Information

Please provide the following information about your office so that we can verify your information below.

Company Name

Doctor's Name

Employee Information

Please provide the following about yourself.

Name

Date of Birth

mm/dd/yyyy

Address:

Phone Number:

Phone

Email Address:

By checking this box, I certify that I have spoken to my employer and confirmed that I am eligible for my office’s 401(k) Plan prior to submitting this form.

Eligibility requirements vary by office. Please verify with your doctor that you are eligible to contribute to the plan prior to continuing.

By checking this box, I certify that I have spoken to my employer and confirmed that I am eligible for my office’s 401(k) Plan prior to submitting this form.

Salary Deferral Election

Election

Pre-tax contributions mean that you save on taxes now and pay upon withdrawal.

Roth contributions mean that you pay taxes now and never pay any taxes on that money again.

I elect to make pre-tax contributions

I elect to make Roth contributions

I currently do not wish to contribute to the plan

Beneficiary Designation

Complete this section to designate a person or people to receive your plan benefits should you die prior to taking a full distribution from the plan.

Marital Status

Married

Not Married

Verification

Signature

Type your full name below to verify that you wish to have the amounts above deducted from your paycheck each pay period and that the designated beneficiary(ies) are accurate.

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