NEW Client Data Intake Form - Initial Enrollment

  • NEW Client Data Intake Form - Initial Enrollment

    This form is for NEW accounts that are new to Colonial. Provide as much information and detail as possible. The more information you provide the better we can serve you and the group.
  • Has CASSHM already been completed?*

  • If we are offering Unum, Navigator, or Section 125 plans, we NEED to know how the group files for taxes federally. Please find out as soon as possible and let the coordinator team know. If we're doing Unum it is a REQUIRED piece of information.

  • If we have questions about this account, who should we contact?*

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  • Opener Commission Split Required?
  • Rows
  • Broker INFLUENCE*
  • Are any employees outside of the Situs State (primary company state)?*
  • Does the group require multiple classes of employees? i.e. Management/Field, Hourly/Salary - This is for the purposes of different eligibilities or different contributions.
  • How many total employee classifications are required for eligibility/contribution purposes?

  • Single Class New Hire Eligibility*
  • Will we provide the group's Section 125 through AmeriFlex?*
  • What benefits does group currently offer?

  • Enrollment Details

    Please provide as much information as you can - anything the BC may need to know about the group including personality of the PA, employee demographics, etc.
  • Have you logged this enrollment in to Agent Assist?
  • Enrollment Type*

  • Gathr Billing*
  • First Deduction Date following CED*
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  • Second Deduction Date following CED*
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  • Is the Casto team building the Core enrollment platform?
  • Is the EN license under Megan's General Agency license or another Broker license?
  • Core Benefits to be offered in this enrollment

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  • Are any existing carrier benefits being replaced by Colonial?*
  • Has an enrollment date been scheduled & confirmed with the account?*

  • REMINDER - If no date is confirmed your account will be processed as time is available. Please remember to notify our team as soon as a date is confirmed.

  • First Enrollment Scheduled Date
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  • Expected Enrollment End Date
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  • Enrollment Working Conditions*

  • BC SELECTION EXPECTATIONS

    In person enrollments - please schedule your benefits counselor directly and select them below once confirmed. If you need assistance in booking a BC for an on site enrollment contact your territory enrollment team.

    Virtual Enrollments - please select your BC preference(s) or "no preference". BCs will be booked based on availability, licensing, and fit for the group. Your preference may not be available. Multiple BCs may be assigned to virtual enrollments.

    Agents are expected to book employee appointments for virtual appointments or work with the group to ensure appointments are booked by EEs. BCs are NOT required or expected to call and book EE appointments.


    If you ask for us to book a benefit counselor we will do our best to schedule your preferenced selection but make no guarantee of their availability.

     

  • Please select the BC you've booked or if you have a preference BC,s please select them here. If no preference, a BC will be assigned based on availability.

  • COLONIAL Employer Contribution?*
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  • Which Complimentary Benefits do you want to offer?*
  • POP offer? Requires 10+ eligible EEs. Must meet with 75% of EEs. CANNOT BE OFFERED WITH EMPLOYEE NAVIGATOR OR EASE.
  • Do you want our team to create a Digital Postcard for the group? Card will be sent to Sales Contact/Opener unless otherwise specified.*
  • Calendly Schedule Link Required?*
  • What date do you need digital card or calendly set up by to send to client?
     - -

  • Product Details

    Select Product & Options needed for enrollment event. Please consider limiting the number of products offered in the first enrollment.
  • Are we offering Unum Products through CBS?
  • Has the Sold Case form been submitted to home office?

  • If you have already submitted a quote request, please send that to Megan.Casto@ColonialLifeSales.com.  If you need a quote request submitted, send the quote census with information on the products you want to quote.

  • CBS Vision?*
  • CBS Short Term Disability*
  • CBS Long Term Disability*
  • CBS Group Term Life*
  • GTL ER Paid Face Value

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  • CL Individual Disability*
  • Individual Disability plan:
  • Benefit Period
  • Include in the STD Plan Design (not an optional rider!):
  • Individual Accident*
  • Individual Critical Illness*
  • CI Plan Design
  • Individual Cancer*
  • Individual Medical Bridge (Hospital Plan)*
  • Plan Level Offering
  • Select desired hospital level. Only 2 allowed and cannot be more than $1,000 apart. $4k & $5k require UW approval.
  • Additional IMB Settings
  • Dental - PPO*
  • Ind Dental 8000 - Plan Offering (2 max) - Cannot offer more than one Plan 4 or Plan 5 at one time. *Standard setup will be Plan 4 Premier & Plan 5 Premier unless otherwise marked.
  • Ind Dental 8100 - Plan Offering (2 Max)*
  • Include in Dental PPO 8000 Plan Design:*
  • Are we offering Ortho as part of the 8100 plan design? This will apply to all employees and is not a rider.*
  • Are we applying the Waiver of Waiting Period for Class C Services (NOT the same as a TAKEOVER)? THIS WILL INCREASE RATES.
  • Is this a dental takeover? REQUIRES ADDITIONAL INFORMATION

  • If we are replacing an existing dental carrier with Colonial, to provide credit for time insurred, you must provide a copy of the existing carrier invoice showing participation and existing plan design. Email this to your coordinator team as soon as possible.

  • Include Vision Rider
  • Dental Fee Schedule*
  • Individual Term Life 5000*
  • Whole Life 5000*
  • Offering COLONIAL Group Plans?*
  • Confirm the Group Plans Being Offered:
  • Should be Empty: