Request for Proposal Form
Company Information
Company Name
*
Nature of Business
*
Email
*
example@example.com
Phone Number
*
Please enter a valid phone number.
Company Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Mailing Address, if different from Company Address
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Company Website
Please provide URL
Does the group have employees in other U.S. states, territories, and/or protectorates? If so, please list all that apply.
This is important in order to propose the correct products. For example, in New York State 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
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Payroll Frequency
*
Please Select
Bi-weekly (26 deductions)
Bi-weekly (24 deductions)
Semi-monthly (24 deductions)
Monthly (12 deductions)
20 Pay
Weekly (52 deductions)
Weekly (48 deductions)
Anticipated medial plan deductions, out of pocket maximums, and/or HSA compatible plan needed?
This is helpful information in aligning our benefits in order to create the best benefits package available to you.
Colonial Life Benefits
If GTL or Group Disability quotes are needed, please provide a census which includes Gender, Age/DOB, and Salary.
Attached Census
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Benefits to include in proposal:
*
Accident
Cancer
Critical Illness
Dental (PPO) / Vision
Long-Term Disability (LTD) (through Unum)
Medical Bridge
Short-Term Disability (STD)
Term Life
Vision (stand-alone through Unum)
Whole Life
Enrollment Services
In order to utilize our enrollment services, we would need at least 3 Colonial Life benefits made available to employees.
Type of Enrollment
*
Please Select
All benefits (Core + Colonial Life)
Colonial Life ONLY
Would you like information about our enrollment services included?
*
Please Select
Yes
No
Enrollment System
*
Please Select
Harmony (Colonial Life system)
Employee Navigator
Ease
Other
If "Other" selected above, please provide system that will be used.
Current Worksite / Voluntary Benefits in-place.
Does the group currently offer Voluntary Benefits (VB)?
Please Select
Yes
No
Unsure
Additional Notes
Broker Information
Please complete, if applicable
Broker Name
First Name
Last Name
Broker Email
example@example.com
Broker Phone Number
Please enter a valid phone number.
Return Proposal to:
First Name
Last Name
Recipient Email
example@example.com
Recipient Phone Number
Please enter a valid phone number.
Proposal Need-by Date
*
-
Month
-
Day
Year
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Signature
*
This is a signature field. Please click in the box, if able, to sign.
Date Submitted
-
Month
-
Day
Year
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Hour Minutes
AM
PM
AM/PM Option
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