Proposal Request Form
Company Information
Legal Company Name
*
include dba if applicable
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
Company Website
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
*
-
Month
-
Day
Year
Date
Pay frequency?
*
Bi-Weekly (26 deductions)
Bi-Weekly (24 deductions)
Semi-Monthly (24 deductions)
Monthly (12 deductions)
20 Pay
Weekly (52 deductions)
Weekly (48 deductions)
Anticipated medical plans deductibles, out of pocket maximums, HSA compatible plan needed?
This is so we can align our benefits to create the best benefits package.
Attach Census
Browse Files
Cancel
of
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:
*
Accident
Cancer
Critical Illness
Dental (PPO)/Vision
STD
Medical Bridge
LTD (through Unum)
Vision (stand alone through Unum)
Term Life
Whole Life
Enrollment Services
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)
Colonial only
Do you want information about our enrollment services included?
*
Please Select
Yes
No
Enrollment System
*
Harmony (Colonial's system)
Employee Navigator
Ease
Other
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)?
No
Yes
Unsure
Please upload current VB invoice and plan designs
Browse Files
Cancel
of
Additional Notes:
Broker Information
Broker Name
*
First Name
Last Name
Email
*
example@example.com
Phone Number
*
-
Area Code
Phone Number
Return Proposal to:
First Name
Last Name
Email
example@example.com
Date Submitted
-
Month
-
Day
Year
Submit
Should be Empty: