EXISTING Client Data Intake Form - Rework or New Hire Enrollment

EXISTING Client - New Hire OR Open Enrollment

This form is for existing accounts that have a new hire, open enrollment, or other enrollment event needed. 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 Contact
KOP or District Account Manager who needs this information or can answer questions/help with the group
Is this a New Hire event or an Open Enrollment event?*

New HireOpen EnrollmentOther
Please allow a minimum of 48 business hours for processing open enrollment events.
Account Name*
Include DBA name as well as Legal name.
Account BCN
Changes to Opener Required?

YesNo
Change Opener to

First NameLast NameAgent Code
Opener Commission Split Required?

NoYes

Sales Contact if different than Main OP

First NameLast NameAgent Code
Broker Influence

NoneBroker - No CommissionBroker - Commission Required
Broker Name & Code

First NameLast NameBroker Code
Broker Commission Schedule
If a different commission schedule is needed, enter into the comment section.
Confirm total Eligible Employees to be seen during this enrollment:
How many EEs work 20+ Hours/Week? Have there been changes to total from last enrollment?
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
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.
Open Enrollment Type - did we previously enroll core? will that remain?

Voluntary OnlyCore & Colonial EnrollmentAgent Assisted Core CommunicationOther
Open Enrollment System
What other benefits does group offer?

No BenefitsMedicalHSADentalVisionLTDSTD (not CL)Life InsuranceOther
Are we making any changes to the Colonial products*

YesNo
Describe Product Changes and details of existing plans remaining in place.
Are new products being added? Are changes needed to existing products offered?
Upload any plan documents, rate quotes, or other files necessary for the enrollment.

Browse Files
Any new quotes for medical, dental, vision can be loaded as well as any CL or Unum rate changes. Cancelof
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
Has an enrollment date been scheduled & confirmed with the account?*

YesNo not yetOther
Expected Enrollment Start Date

MonthDayYear
ACTUAL DATE THAT EMPLOYEES WILL START BEING SEEN, NOT THE START OF THE ENROLLMENT PERIOD
Expected Enrollment End Date (MINIMUM 5 days prior to CED)

MonthDayYear
Based on PED, end date should be a minimum of 10 days prior to first deduction due date.
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 employee 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.
If you have a preference for BC, please select them here. If no preference, a BC will be assigned based on availability. If IN PERSON enrollment, please schedule your BC directly.*

No PreferenceAngie RamirezCarla ReelCaryl EstesDavid BarneyGlenn FrenchHeather JonesHeather RichinsHoward HorowitzJanis LukehartJodi MoylanJoel LucasJudy BucholtzKeith LefevreLisa RobbersonLouisa BellotteLuis CardenasMary DaughertyMel KirkseyRandy KruseRon JonesTracy BallTrish DunneZacharee SiahpushOther
Employer Contribution?*

Yes ExistingYes NEWNoNot Confirmed / Maybe
Upload Quote if provided to client

Browse Files

Cancelof
Explain Employer Contribution Details if Changing from Previous Year
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 qualified for Year 2? Requires 10+ eligible EEs and met participation requirements previous enrollment.

NONEMD LiveID GuardAD&DPeak MoneyTo be determined
Calendly Schedule Link Required?*

NoYes - Include all details in commentsOther
Is Call Center enrollment only required? i.e. are there employees who don't have access to a computer for screen sharing?

NoYes
Explain working conditions - communication plan, Times for calendly, BC accommodations, etc.
Product Details

Select Product & Options and any changes needed for enrollment event.
Are we making changes to the product offering for this enrollment?

Yes - note changes belowNo ChangesOther
Short Term Disability (State specific)*

ISTDDIP3000None
Benefit Periods (will be set up based on state/product restrictions)

3 Months6 Months12 Months24 Months
Depending on benefit periods, first day hospital and mental/nervous disorders will be elected unless unchecked. State requirements may dictate selection.

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

YesNo
Critical Illness 1.0*

Yes CI OnlyNoYes CI+CAN
Cancer Assist*

YesNo
Individual Medical Bridge (Hospital Plan)*

YesNo
Plan Level Offering (State specific setup will apply)

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 (State specific requirements will apply)

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

YesNo
Offering the PPO 8000 or PPO 8100?*

80008100
Dental 8000 Plan Offering (2 max)

Plan 1 $1,000 100/60/40Plan 2 $1,000 100/80/50Plan 3 $1,500 100/80/50Plan 4 $2,000 100/80/50Plan 4 $2,000 PREMIER 100/80/50 (Standard)Plan 5 $1,000 PPO ADVANTAGE 100/80/50Plan 5 $1,500 PPO 100/80/50Plan 5 $1,500 PPO PREMIER 100/80/50 (Standard)
Include in Dental PPO 8000 Plan Design:

RolloverOrthodontia (19 and Under)None
Dental 8100 Plan Offering (2 Max)*

Preventative Only $750 MACStandard $1,000 MACEnhanced $3000 MAC *Premier $5,000 MACFreedom $1000 PPOFreedom Premier $2000 PPO *Retiree $1,500 MAC
Include Vision Rider

YesNo
Include 8100 Orthodontia Rider*

YesNo
Dental Fee Schedule*

YesNo
Term Life 5000*

YesNo
Whole Life 5000+*

YesNo
New Offering Group Plans?*

No new Group Plans - Existing Group Remain in PlaceYes, new group plans being offeredOther
Which Group plans are being offered?
Include product type, 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
First Split
Second Split
Third Split
Fourth Split

EXISTING Client - New Hire OR Open Enrollment

Enrollment Details

Product Details