NEW Client Data Intake Form - Initial Enrollment

NEW Client Data Intake Form - Initial Enrollment

This form is for NEW accounts that are new to Colonial. Provide as much information and detail as possible. The more information you provide the better we can serve you and the group.
Your email address*
example@example.com
Your ADM's Email
example@example.com
Your DGA's Email*
example@example.com
Account Manager / KOP Support
Add the email address of your support person if needed.
Account Name*
Include DBA name as well as Legal name.
Has CASSHM already been completed?*

NoYes
Account BCN
Please provide if known
Account CAN
Please provide if known
FEIN*
This is REQUIRED for Section 125 Docs (AmeriFlex) and integrations. If unknown, enter 000000000. Don't enter a Dash.
How does the company file for taxes federally?
This is REQUIRED for CBS/Unum groups, Employee Navigator Integrations, and Section 125 Plan Documents. If you don't yet know, please find out as soon as possible.
If we are offering Unum, Navigator, or Section 125 plans, we NEED to know how the group files for taxes federally. Please find out as soon as possible and let the coordinator team know. If we're doing Unum it is a REQUIRED piece of information.
Payroll Processor
Optional, but helpful to know when building systems and returning deductions.
If we have questions about this account, who should we contact?*

DGAADMOpenerOther
Main Opener & CASE COUNT Assigned to:*

First NameLast NameAgent Code
Assigned Opener Phone Number*

Area CodePhone Number
SALES CONTACT - if different than Main Opener

First NameLast NameAgent Code
Opener Commission Split Required?

NoYes

Broker INFLUENCE*

Broker - NO CommissionBroker - Commission RequiredNone
Broker Name/Agency & Code

First NameLast NameIf No Commission, Enter the code as 000000
Broker Commission Schedule
If a different commission schedule is needed, enter into the comment section.
Other BK Comp Schedule
MPL (Map Pinnacle Levelized), MKL (Map Peak Levelized), MPN (Map Pinnacle High/Low), MPK (Map Peak High/Low)
Total Eligible Employees
How many EEs work 20+ Hours/Week or are considered benefits eligible by the company?
Are any employees outside of the Situs State (primary company state)?*

YesNoUnsure
Does the group require multiple classes of employees? i.e. Management/Field, Hourly/Salary - This is for the purposes of different eligibilities or different contributions.

No - one class onlyYes - Multiple Classes
How many total employee classifications are required for elligibility/contribution purposes?

2345Other
Outline eligibility and contribution details for the multiple classes.
SAMPLE
Class 1 Field - 1st after 60, $50 Benefit Bank
Class 2 Manager - 1st after 30, $100 Benefit BankClassifications are important when building out enrollment platforms. Keep in mind some groups may also want an Owner class separate from the other classes.
Single Class New Hire Eligibility*

1st After Hire Date1st after 30 Days1st after 60 Days1st after 90 Days1st after 180 Days1st after 365 Days
Will we provide the group's Section 125 through AmeriFlex?*

YesNo - they have one in placeNo - Post Tax Only
What benefits does group currently offer?

No BenefitsMedicalHSADentalVisionLTDSTD (not CL)Life InsuranceOther
Enrollment Details

Please provide as much information as you can - anything the BC may need to know about the group including personality of the PA, employee demographics, etc.
Have you logged this enrollment in to Agent Assist?*

YesNo
Enrollment Type*

Voluntary (Colonial) OnlyAgent Assisted Core & Colonial EnrollmentAgent Core CommunicationOther
Enrollment System*
Is the Casto team building the Core enrollment platform?

YesNo
Is the EN license under Megan's General Agency license or another Broker license?

Megan's GA LicenseAnother Broker LicenseUnsure
Which broker Navigator license is being used?
Make sure Megan is introduced or set up to access the broker's EN to build Colonial plans.
Core Benefits to be offered in this enrollment

Medical InsuranceDental Insurance (non-Colonial)Vision InsuranceDisability (non-Colonial)Life Insurance (non-Colonial)HSAFSAOther
Upload the FULL rate quote for any/all carriers being built out.

Browse Files
This should be a FULL rate table, not calculated by pay period or reduced by employer contribution. The full monthly rate per employee/dependent. Cancelof
Are any existing carrier benefits being replaced by Colonial?*

YesNo
Describe Product Replacements and details of existing plans.
Which products are being replaced? Send copies of existing plans. Is Credit for Time Served needed?
Has an enrollment date been scheduled & confirmed with the account?*

YesNo not yetOther
REMINDER - If no date is confirmed your account will be processed as time is available. Please remember to notify our team as soon as a date is confirmed.
Processing Acknowledgement

I understand that I need to notify the CD team as soon as a date is set for enrollment. This group will not be ready for enrollment until additional communication is received and an enrollment start date confirmed and that the team needs 48 BUSINESS HOURS to finalize an account for an Initial enrollment, if all data is received and group is released from HO.
First Enrollment Scheduled Date

MonthDayYear
Date the BCs are expected to start meeting employees. NOT the initial enrollment period defined by the Flex Form
Expected Enrollment End Date

MonthDayYear
When will BCs be done meeting with EEs? This is not the last day of the enrollment period defined by the Flex Form.
Enrollment Working Conditions*

In Person MandatoryIn Person VoluntaryVirtual MandatoryVirtual Voluntary
In Person Enrollment Address if different than main address on AIF. If multiple addresses, enter in comment section.

Street Address

CityState

Zip Code
BC SELECTION EXPECTATIONS

In person enrollments - please schedule your benefits counselor directly and select them below once confirmed. If you need assistance in booking a BC for an on site enrollment contact your territory enrollment team.

Virtual Enrollments - please select your BC preference(s) or "no preference". BCs will be booked based on availability, licensing, and fit for the group. Your preference may not be available. Multiple BCs may be assigned to virtual enrollments.

Agents are expected to book employee appointments for virtual appointments or work with the group to ensure appointments are booked by EEs. BCs are NOT required or expected to call and book EE appointments.

If you ask for us to book a benefit counselor we will do our best to schedule your preferenced selection but make no guarantee of their availability.
Please select the BC you've booked or if you have a preference BC,s please select them here. If no preference, a BC will be assigned based on availability.

No PreferenceCarla ReelCaryl EstesDavid BarneyHeather JonesHeather RichinsJanis LukehartJodi MoylanJoel LucasJudy BucholtzKeith LefevreLisa RobbersonLuis CardenasMary DaughertyMel KirkseyRandy KruseRon JonesTracy BallTricia DunneZacharee SiahpushAngie RamirezRay BlazakJenny WoolleyGlenn FrenchOther
COLONIAL Employer Contribution?*

Yes Product SpecificYes Benefit BankNoNot Confirmed / Maybe
Upload Quote if provided to client

Browse Files

Cancelof
Explain Colonial Employer Contribution Details
Benefit Bank amount, product specific details (be specific - include quotes if provided to account)
Which Complimentary Benefits do you want to offer?*

Law AssureKOFEWell CardNone
POP offer? Requires 10+ eligible EEs. Must meet with 75% of EEs. CANNOT BE OFFERED WITH EMPLOYEE NAVIGATOR OR EASE.

NONETelemedicineID GuardAD&DTo be determined
Do you want our team to create a Digital Postcard for the group? Card will be sent to Sales Contact/Opener unless otherwise specified.*

YesNo
Calendly Schedule Link Required?*

NoYes - Include details in comments
What date do you need digital card or calendly set up by to send to client?

MonthDayYear
Date
Explain working conditions - communication plan, BC accommodations, etc.
Product Details

Select Product & Options needed for enrollment event. Please consider limiting the number of products offered in the first enrollment.
Are we offering Unum Products through CBS?

YesMaybe - Quote NeededNo
Has the Sold Case form been submitted to home office?

No - can Megan do it?No - but Opener will do itYes - Submitted!
Who will be the Opener assigned for CBS commission?
This is typically the Colonial account opener.
If you have already submitted a quote request, please send that to Megan.Casto@ColonialLifeSales.com. If you need a quote request submitted, send the quote census with information on the products you want to quote.
CBS Vision?*

NoneYes
CBS Short Term Disability*

NoneYes - Employer Paid 3MYes - Voluntary 3MYes - Employer Paid 6MYes - Voluntary 6M
CBS Long Term Disability*

NoneYes - Voluntary 90 DaysYes - Employer Paid 90 DaysYes - Voluntary 180 DaysYes - Employer Paid 180 Days
CBS Group Term Life*

NoneYes - Basic OnlyYes - Voluntary OnlyYes - Basic & Voluntary
GTL ER Paid Face Value

Flat $25kFlat $50k1x Salary to $50k1x Salary to $100kOther
Upload SOLD Case Quote - and Email final email to Megan

Browse Files

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CL Individual Disability*

YesNo
Individual Disability plan:

ISTD 3000DIP3000
Benefit Period

3 Months6 Months12 Months24 Months
Include in the STD Plan Design (not an optional rider!):

First Day Hospital Waiver (only on 30 EP or less)Mental/Nervous DisorderNone
CL Accident - IA 4000*

YesNo
CL Critical Illness 1.0*

YesNo
CI Plan Design

CI Stand AloneCI+CAN
CL Cancer Assist*

YesNo
Individual Medical Bridge (Hospital Plan)*

YesNo
Plan Level Offering

Plan 1 (HSA Compliant)Plan 2 (not standard)Plan 3 (default)
Select desired hospital level. Only 2 allowed and cannot be more than $1,000 apart. $4k & $5k require UW approval.

$500 PEGI Available$1,000 PEGI Available$1,500 PEGI Available$2,000 Full UW$2,500 Full UW$3,000 Full UW$4,000 UW Approval Required$5,000 UW Approval Required
Additional IMB Settings

Medical Treatment Package (Standard)Health Screening $50 (Standard)ICU Rider (Standard)Daily Hospital Rider (Standard)
Dental - PPO*

Yes PPO 8000NoYes PPO 8100
Ind Dental 8000 - Plan Offering (2 max) - Cannot offer more than one Plan 4 or Plan 5 at one time. *Standard setup will be Plan 4 Premier & Plan 5 Premier unless otherwise marked.

8000 - Plan 1 $1,000 100/60/408000 - Plan 2 $1,000 100/80/508000 - Plan 3 $1,500 100/80/508000 - Plan 4 $2,000 100/80/508000 - Plan 4 $2,000 PREMIER*8000 - Plan 5 $1,000 PPO Advantage8000 - Plan 5 $1,500 PPO 100/80/508000 - Plan 5 $1,500 PPO PREMIER*
Ind Dental 8100 - Plan Offering (2 Max)*

8100 - Preventative Only MAC $7508100 - Standard MAC $1,0008100 - Enhanced MAC $3,000 (RECOMMENDED)8100 - Premier MAC $5,0008100 - Freedom PPO $1,0008100 - Freedom Premier $2,000 (RECOMMENDED)
Include in Dental PPO 8000 Plan Design:*

RolloverOrthodontia (19 and Under)None
Are we offering Ortho as part of the 8100 plan design? This will apply to all employees and is not a rider.*

YesNo
Are we applying the Waiver of Waiting Period for Class C Services (NOT the same as a TAKEOVER)? THIS WILL INCREASE RATES.

YesNo
Is this a dental takeover? REQUIRES ADDITIONAL INFORMATION

NoYes
If we are replacing an existing dental carrier with Colonial, to provide credit for time insurred, you must provide a copy of the existing carrier invoice showing participation and existing plan design. Email this to your coordinator team as soon as possible.
Include Vision Rider

YesNo
Dental Fee Schedule*

YesNo
Term Life 5000*

YesNo
Whole Life 5000*

YesNo
Offering COLONIAL Group Plans?*

Yes - be sure to get the MAPP signedNo group plans offered
Confirm the Group Plans Being Offered:

Group AccidentGroup Critical Care 6000Group Critical IllnessGroup Term Life Basic OnlyGroup Term Life Basic & VoluntaryGroup Term Life Voluntary OnlyGroup Medical Bridge 7000
Explain employer contribution details for Group plans, if any, or if voluntary.
Include employer contribution details, underwriting offer required, classification rules, etc.
Any other product details or information we should know?
Should be Empty:

	Agent Name	Agent Code	% Opener
CASE COUNT Assigned & Split (25% Min)
Second Split % (non Case count)
Third Split % (non Case count)
Fourth Split % (non Case count)

NEW Client Data Intake Form - Initial Enrollment

Enrollment Details

Product Details