Colonial Interest Form

Employeer *

Name *

First

Last

Email *

Phone *

SS#

If left blank we will call you to get this information. We value your privacy.

Annual Income $

Please enter your Annual Salary

Address

Address Line 1

Address Line 2

City

State

Zip Code

Date of Birth

Tobacco

Are you a tobacco user?

Job Title

Date of Hire

Beneficiary

Date of Birth

Relationship

Spouse

First

Last

Relationship

Child-1

First

Last

Child-2

First

Last

Child-3

First

Last

Check One Please

Waive Colonial Coverage. I understand that I can only enroll during Annual Enrollment unless I have a qualified event during the year.
Keep Colonial Life plans the same
Add Colonial Life plans
Add Flex - Annual amount per year. Please enter amount in the next field.

Flex Amount Per Year

Please enter a dollar amount.

Signature *

Please sign here.

Date Submitted *

Please Contact: Rich Mellone 704-907-3997 or Email: Rich@insyncbenefits.com