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 #
Format: 1 (000) 000-0000.
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?
Enrollment States: Please indicate which 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.
Enrollment Services Requested?
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:
Will a High Deductible Health Plan (HSA Compatible) be offered?
ICHRA
ICHRA Proposal Requested?
Requested Broker Commissions for ICHRA (PEPM - for employees enrolled)?
This will be added to TPA's PEPM fee of typically $20 PEPM
What percentage is the employer looking to contribute to medical?
(groups under 50 benefit eligilbe employees)
Do they currently offer medical?
If yes, please include current invoice and plan designs
Click here to download required ICHRA Census Template: ICHRA Census Template

Census must include home zip codes, date of birth and salaries for all benefit eligible employees (and dependents if known they will participate).
ICHRA Quote Documents: Census (please use template above) and current medical information (invoice, plan designs)

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Current Worksite/Voluntary Benefits in Place
Does the group currently offer Voluntary Benefits (VB)?
Current VB Carrier
VB Replacement Strategy
Takeover - Colonial only policies on payroll deduction. Grandfathered - no new policies with current carrier, but existing can stay on payroll deduction.
Current VB Information (last invoice and plan designs/brochures)

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Additional Notes:
Attachment Details:

Quoting Census:
* Group Disability/Group Term Life - must have gender, age/DOB and Salary
* 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:

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Contacts:
Colonial Life Agent you are working with:
First Name Last Name
Broker Information
Broker Involved Case
Broker's Name
First Name Last Name
Broker Agency
include dba if applicable
Broker Email
example@example.com
Broker Phone #
Format: 1 (000) 000-0000.
Account Manager/Marketing Contact Name:
First Name Last Name
Account Manager/Marketing Email
example@example.com
GA Information
GA Involved in Case
GA Agency
include dba if applicable
GA Contact Name
First Name Last Name
GA Contact Email
example@example.com
GA Contact Phone #
Format: (000) 000-0000.
Form Completed By:
In case we have any follow up questions, whom should we reach out to?
Date Submitted

MonthDayYear
Should be Empty:

Colonial Life Proposal Request Form

Company Information

General Benefits Information

Enrollment Services

Colonial Life/Unum Benefits

ICHRA

Current Worksite/Voluntary Benefits in Place

Contacts:

Broker Information

GA Information