Colonial Life Proposal Request Form

Colonial Life Proposal Request Form

Please allow up to 48 hours (2 business days) for a response to this request. We will contact you will any questions we might have to provide the best proposal for you and your client. We appreciate your partnership and for thinking about our Colonial Life team.
Company Information
Legal Company Name*
include dba if applicable
Business Phone #*
Address*

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Company Website
Nature of Business*
SIC Code if possible
Type of Business
General Benefits Information
Benefits Effective Date*

MonthDayYear
Date
Number of Benefit Eligible Employees*
Does the group have employees in other states? If so, please list states.
This is important so we propose the right products. In New York similar products, if approved, are underwritten by The Paul Revere Life Insurance Company.
Enrollment Services

In order to utilize our enrollment services and/or enrollment database builds, we need at least 3 Colonial benefits made available to the employees.
Type of Enrollment*
Working Conditions*
Enrollment System*
Select the system to be used if our enrollment services are utilized.
Please name other system
Payroll System
Colonial Life/Unum Benefits

If Group Term Life (GTL) or Group Disability quotes are requested, please send a census with gender, age/DOB, and salary. Group plans with a situs state of FL require 51+ benefit eligible employees to quote (except GTL - Basic ER paid can go down to 10+ employees)
Benefits to include in proposal:*

AccidentShort-Term Disability (STD)CancerLong-Term Disability (LTD)Critical IllnessMedical Bridge (Hospital Confinement)Voluntary Term Life (Group/Individual)VisionGroup Term Life (Basic - ER Paid)DentalWhole Life
Will a High Deductible Health Plan (HSA Compatible) be offered?
ICHRA Proposal Requested?
Current Worksite/Voluntary Benefits in Place
Does the group currently offer Voluntary Benefits (VB)?
Additional Notes:
Attachment Details:

Quoting Census:
* Group Disability/Group Term Life - must have gender, age/DOB
* Unum Dental/Vision - also requires zip code

Other Documents:
* Current Voluntary Benefits - Current Invoice, Plan designs, and Premiums

If quoting ICHRA, additional information needed:
* Prior health plan design(s) (if applicable) w/ participation information
Attachments:

Cancelof
Broker Information
Broker Name*

First NameLast Name
Broker Agency*
include dba if applicable
Broker Email*
example@example.com
Broker Phone #*
Account Manager/Marketing Name*

First NameLast Name
Account Manager/Marketing Email*
example@example.com
Date Submitted

MonthDayYear
Should be Empty:

Colonial Life Proposal Request Form

Company Information

General Benefits Information

Enrollment Services

Colonial Life/Unum Benefits

Current Worksite/Voluntary Benefits in Place

Broker Information