This is an application for Group Insurance. You are not required to complete this form electronically. You may download the form, print, complete & return the printed form to us. If you would like to complete this application electronically, please proceed, otherwise click Download Form.

DBL Only (requires Home Office approval)

PFL Only

Group Life

STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK

NEW YORK DISABILITY BENEFITS, PAID FAMILY LEAVE INSURANCE, & GROUP LIFE APPLICATION

The undersigned employer hereby applies for a policy of group insurance. No insurance shall be binding unless and until
this application is approved by Standard Security Life Insurance Company of New York (SSL). Paid Family Leave coverage (PFL) is
provided at the benefit amounts and duration required under WCL §204(2). PFL does not cover out of state employees.

*Required

Employer Informtion:

1. *Full Legal Name of Employer:

Doing Business as Name: (if applicable)

2. *Physical Address:

Suite or Floor No.:

*City:

*State: *Zip Code:

3. Mailing Address:

Suite or Floor No.:

City:

State: Zip Code:

4. *Telephone Number:

Contact Person:

Contact Email:

5. Type of Business:

Nature of Business or SIC Code

6. Form of Organization:

CorporationLLCPartnershipSole ProprietorOther

7. NY Employer Registration (UI) #:

8. *Federal Taxpayer ID #:

9. *Requested Effective Date:

(Note: Workers' Compensation Board requires receipt within (30) days)

Billing Informtion:

10. *Billing Delivery Mode:

Email Copy of BillPaper Copy of Bill

Email:

Note: Please consider email option, as it allows delivery to multiple copies.

Name:

Phone:

11. *Billing Mode:

AnnuallyQuarterlyMonthly

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)

DBL:

Monthly Per Capita Rates

Male $

Female $

Payroll Rate Factor

Per $100 of Covered Payroll (maximum $340 per week)

Additional Covered Legal Name/FEIN or Location(use an extra sheet of paper if necessary):

14. Name:	Physical Address (if any):	City/State/Zip Code:	Additional Federal Taxpayer ID# (if any):	Separate Billing:
				YesNo YesNo

15. Covered Employees

All eligible under NYS Disability and Paid Family Leave Benefits Law
All except the following (class or classes to be excluded)

16. Employee Contribution

ContributoryNon-Contributory

Voluntary Coverages

If voluntary coverage is elected by a sole proprietor (SP), a member of a limited liability company (LLC), a member of a limited liability partnership (LLP) or other self-employed person (SEP), SSL shall subject the applicant to a waiting period of 2 years before benefits are payable, unless the policy is issued within 26 weeks of when the employer first becomes a sole proprietor (SP), LLC, LLP, or other SEP. An SP with employees, a member of an LLC with employees, a member of an LLP with employees or other SEP with employees, shall be covered under the same policy that cover’s the policyholder’s employees.

17. Names of Proprietors/Partners to be covered:

Date Employer First Became Proprietor/Partner

Opt IN- DBL&PFL Note - Please mark this option if you desire to have the above-mentioned name(s) covered for DBL & PFL.

18. Other Voluntary Classes (requires prior approval by the NYS WCS Plans Acceptance Unit through employer submission of form DB-135 / DB-136)

Opt IN-DBL&PFL

19. Optional Coverages for DBL

A. In-Hospital Supplement

DOUBLE (additional 10% of preminum)TRIPLE (additional 25% of preminum)

B. DBL 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
Plan A	50% to $200	Plan D	50% to $350	Plan G	50% to $500	Plan J	60% to $300
Plan B	50% to $250	Plan E	50% to $400	Plan H	60% to $200	Plan K	60% to $350
Plan C	50% to $300	Plan F	50% to $450	Plan I	60% to $250	Plan L Custom	% to $

20. Optional Benefit: Guaranteed Issue Group Term Life Insurance - NY Employees Only (choose one option only):

Benefit Amount: $15,000 Cost: $3.00 per employee, per month

21. Worker's Compensation Carrier:

22. Previous Disability Carrier:

23.	*Agent or Broker:	*Code #
Address:
City:			State	Zip

23.	SubAgent*:	Code #
Address*
City*			State*	Zip*
Email: *

By completing the application and checking the box, you do hereby agree that: 1) you are the individual named above 2) you are duly authorize to execute this application 3) you are authorized to receive and have permission from the employer named on this application to receive documents electronically, including policy and certificate documents and 4) you have reviewed and approved the information within the application to be true, accurate and complete to the best of your knowledge.

It is your intent, to electronically sign this document by TYPING YOUR NAME BELOW. By submitting this electronic document to Standard Security Life Insurance Company of New York in this way, you understand that your electronic signature and submission is the legal equivalent of having placed your handwritten signature and affirmation on the submitted document and affirming to the truth of the information contained therein.

NOTICE - 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 stated value of the claims for each such violation. (PLEASE NOTE - This is not applicable to the life insurance coverage.)

*Signed at:

this

day of

, 20

*Employer:

*By:

Title:

Submit

Notes: (included in the email)


Yes, thanks. No, not at this time.