Proposal Request Form
Legal Company Name
include dba if applicable
Nature of Business
SIC Code if possible
Street Address Line 2
State / Province
Postal / Zip Code
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.
General Benefits Information
Number of Benefit Eligible Employees
Benefits Effective Date
How would you like premiums shown?
Bi-Weekly (26 deductions)
Bi-Weekly (24 deductions)
Semi-Monthly (24 deductions)
Monthly (12 deductions)
Weekly (52 deductions)
Weekly (48 deductions)
Anticipated medical plans deductibles, out of pocket maximums, HSA plan?
This is so we can align our benefits to create the best benefits package.
Colonial Life Benefits
If GTL or Group Disability quotes are needed please send a census with gender, age/DOB, and salary.
Benefits to include in proposal:
in order to utilize our enrollment services, we need at least 3 Colonial benefits made available to the employees.
Type of Enrollment
All Benefits (Core + Colonial Life)
Harmony (Colonial's system)
Select the system to be used if our enrollment services are utlizied.
Please describe other
Current Worksite/Voluntary Benefits in Place
Does the group currently offer Voluntary Benefits (VB)?
Please upload current VB invoice and plan designs
Return Proposal to:
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