Plan Administrator Web Site Request Form

ColonialConnect for Plan AdministratorsSM Web Site Access

If you handle the administration of your company's bill with us and would like to take advantage of a secure web site for plan administrators, please complete a request form.

* indicates required fields

Request Access for Plan Administrator Web Site
	* Account Name:
	* Account Billing Control Number:
	Additional Account Billing Control Numbers:
	* First Name:
	* Middle Initial:
	* Last Name:
	* Phone Number:	- - ext.
	* Your email Address:
	* What is your relationship?
	If Other please explain:
	Are you interested in learning more about Ez Billing?	Yes No



	Colonial Supplemental Insurance products are underwritten by: The Paul Revere Life Insurance Company, Worcester, MA Administrative Office: Colonial Supplemental Insurance Division, 1200 Colonial Life Blvd, Columbia, SC, 29210	Important Legal Notice
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