New Account Setup Form
Company Information
Legal Company Name
*
include dba if applicable
Group Tax ID Number
*
Type of Company
*
Sole Proprietor
Partnership
LLC
S-Corp
C-Corp
Non-Profit
Nature of Business
*
SIC Code if possible
Phone Number
*
-
Area Code
Phone Number
Physical Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Different mailing address
*
No
Yes
Mailing Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Website
General Benefits Information
Number of Benefit Eligible Employees
*
Benefits Effective Date
*
-
Month
-
Day
Year
Date
Eligibility Period
*
date of hire (DOH)
1st following hire (FOM DOH)
1st following 30 days (FOM 30 days)
1st following 60 days (FOM 60 days)
90th day
New Hire Waiting Period Waived for Initial Enrollment?
*
No
Yes
Domestic partners allowed on benefits
*
No
Yes
Varies per plan
Please describe in detail if domestic partner eligibility varies by plan
Domestic partner requirements
*
Company Contact
We must schedule a set-up call with the group contact as soon as possible. This is for verification purposes in establishing them as a Colonial account and ensuring the invoice is correctly set up.
Company Contact Person
*
First Name
Last Name
Job Title
*
Company Contact Phone Number
*
-
Area Code
Phone Number
Email
*
example@example.com
2nd Contact Person required
*
No
Yes
2nd Company Contact Person
First Name
Last Name
Job Title
Company Contact Phone Number
-
Area Code
Phone Number
Email
example@example.com
Payroll Information
Payroll Frequency
*
Bi-Weekly (26 deductions)
Bi-Weekly (24 deductions)
Semi-Monthly (24 deductions)
Monthly (12 deductions)
20 Pay
Weekly (52 deductions)
Weekly (48 deductions)
Day of the week paychecks are received?
*
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
First deductions after effective date
*
-
Month
-
Day
Year
Date
Payroll System Used
*
Is the group interested in pursuing a payroll connection?
*
No
Yes
Colonial Life Billing
Billing Frequency
*
Monthly
Per Deduction
Deductions taken from every paycheck?
*
No
Yes
Bill sorted by employee last name
*
No
Yes
our billing includes last 4 of SSN
If no, please description how bill needs to be sorted
Are employee numbers need on bill?
*
No
Yes
Enrollment Details
Language Needs:
*
Employee Work Shifts
*
Type of Enrollment
*
Mandatory
Voluntary (Passive)
Benefit Enrollment choose all that apply
*
1-on-1 Onsite
1-on-1 Virtual
Call Center
Self-Enrollment
Enrollment System
*
Harmony (Colonial's system)
Employee Navigator
Ease
Other
Minimum group size for us to build Employee Navigator and Ease is 10.
Please describe other
POP Plan
*
Colonial (through Ameriflex)
Other Source
Please describe other
Enrollment Deadline
*
-
Month
-
Day
Year
Date
Will we be capturing HSA (savings account deductions) or FSA?
Please Select
No
Yes - FSA
Yes - HSA
Yes - FSA & HSA
Does employee select bank or employer?
Please Select
Employee Selects & Sets Up Account on Their Own
Employer Selects & Sets Up for Employee
Employer Selects & Employee Sets Up
If Employer selects, please list name of company.
New Account Enrollment Build
Please upload all of the following:
ALL information must be submitted 10 business days prior to the start date of the enrollment.
Upload Plan Setup Documents
Browse Files
Cancel
of
Census Template
Please Remember:
Click here for the Colonial Life
Enrollment Census Template
Dependent age limitation by product
*
PCP election required:
*
No
Yes
Late entrant penalty on dental?
*
No
Yes
Spouse voluntary life based on...
*
Employee age
Spouse age
Medical Deductible type
*
Embedded
Non-Embedded
Varies by Plan
Deductible resets
*
Calendar Year
Plan Year
Additional Details for Employee Navigator or Ease database builds
Please complete if this information if known, it will be needed/asked for in order to complete the database build.
Dependent age restrictions
day of
end of the month
end of the year
varies by plan - details will be sent separately
Salary based plans (effective date rule for change when salary updates throughout the year)
day of
1st of month following
policy anniversary date
Age-banded plans - New hire enrollments should be based on the applicant age
Calculated eligibility date
Prior policy anniversary
Will this system be used for ACA reporting?
No
Yes
Does this group need carrier feeds (834) setup?
No
Yes
If yes, information needed for feed setup will vary by group & carrier. Please provide a broker-side contact for ongoing feed setup communication.
Post enrollment training requested for HR user(s)?
No
Yes
Broker Information
Broker Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Account Manager's Name
First Name
Last Name
Account Manager's Email
example@example.com
Account Manager's Phone Number
-
Area Code
Phone Number
Signature
*
Clear
Date Signed
-
Month
-
Day
Year
Date
Submit
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Underwriting/Broker Notes
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