The undersigned employer hereby applies for a policy of group insurance to provide benefits
in accordance with Section 204 of the New York Disability Benefits Law,
to be used in reliance on the statements made in this application.
No insurance shall be binding unless and until this application is approved at the Home Office of the Company.


1. *Employer
2. *Business Address Suite or Floor No.        
*City *State *Zip Code
3. Billing Address (If Different Than Above) Suite or Floor No.        
City State Zip Code  
4. *Telephone Number: Contact Person:    
Contact Email: 5. SIC Code:  
6. Form of Organization
7. NY Employer Registration (UI) #: 8. *Federal Taxpayer ID #:
9. *Requested Effective Date of Coverage: (Note: Workers' Compensation Board requires receipt within (30) days).
10. *Billing Delivery Mode
11. *Billing Mode
12. *No. of Employees to be Insured       DBL Male Female Total DBL:
PFL Male Female Total PFL:
13. DBL Groups of 50 or More Lives (rates require prior approval by underwriter)
Male $ Female $
Per $100 of Covered Payroll (Maximum $340 per week)
14. Covered Employers              
Name: Address: City/State/Zip Code: Fed ID#: Billed Separately (Yes/No)

15. Covered Employees
16. Employee Contribution
17. Names of Proprietors or Partners to be covered: Date Employer First Became Proprietor/Partner
18. Other Voluntary
19. Optional Enriched DBL Coverages          
A. In-Hospital Supplement
B. Enriched Benefit            
The following plans apply to groups with 1-49 lives only. Custom enriched plans for groups with 50+ lives are available with underwriting approval.
Maximum Weekly Benefit
50% to $200
50% to $250
50% to $300
50% to $350
50% to $400
50% to $450
Maximum Weekly Benefit
50% to $500
60% to $200
60% to $250
60% to $300
60% to $350
 % to $ 
20. Worker's Compensation Carrier:
21. Previous Disability Carrier:
22. Agent or Broker: 23. SubAgent*:
Address:   Address*  
City City*
State Zip State* Zip*
Code # Code # Email*
"Any person who knowingly and with intent to defraud any insurance company or other person files an application for insurance or statement of claim containing any materially false information, or conceals for the purpose of misleading information concerning any fact material thereto commits a fraudulent insurance act, which is a crime and shall also be subject to a civil penalty not to exceed five thousand dollars and the state value of the claim for each such violation."
By checking the box below, I do hereby attest that: 1) I am the individual whose name appears below; 2) I am duly authorized to execute this application; 3) I am executing this application on behalf of the Employer named below; and 4) I have reviewed and approved the information contained herein and the information is true, accurate and complete to the best of my knowledge.
on this day of , 20

Notes: (included in the email)

Submit Application