Agent Information
Agent Name
*
First Name
Last Name
Agent Number
*
Account Information
Please read all questions carefully. Questions without an asterisk are not required but are available for additional information you would like to provide to coordinators
Account Name
*
Account Address
*
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Account Contact
*
First Name
Last Name
Account Contact Email
*
example@example.com
Additional Account Emails
Number of Employees
*
Deduction Frequency
*
52 deductions
26 deductions
24 deductions
12 deductions
Deduction Frequency Rules
Employer Contributions
*
None
Employer Paid Plan
Benefit Bank
Benefit bank amount is:
$
monthly.
Enrollment Start Date
*
-
Month
-
Day
Year
Date
Additional Location Dates and Addresses
First Deduction Date
*
-
Month
-
Day
Year
Date
Enrollment Tax Status
*
Post-Tax
Pre-Tax
Tax-ID
Section 125 Questions
State of Legal Construction
Is this a Church or Government
No
Church
Government
Legal Entity Type
LLC.
Sole Proprietorship
Partnership
S-Corp
C-Corp
Non-Profit
Government Entity
Core Benefits
Health
HSA
Vision
Dental
Cancer
Group Term Life
Disability
Accident
Bridge/Gap
Hospital Confinement
Other
Enrollment Questions
Which enrollment platform will you use?
*
Harmony
EASE
ENav
Which enrollment method will you use?
*
Face to Face
Co-Browsing
Telephonic
Virtual Enrollment Details
Will Core be enrolled by Colonial Life Team?
*
No
Yes
Additional notes
Document Upload
AIF
*
Browse Files
Cancel
of
Flex Form
Browse Files
Cancel
of
Approved Proposal
*
Browse Files
Cancel
of
Product Offering Rules
Census
Browse Files
Cancel
of
Core Information
Browse Files
Cancel
of
Submit
Should be Empty: