NEW YORK DISABILITY BENEFITS AND PAID FAMILY LEAVE INSURANCE EMPLOYER APPLICATION
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.
*Required
1.
*Employer
2.
*Business Address
Suite or Floor No.
*City
*State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IA
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WI
WV
WY
PR
VI
*Zip Code
3.
Billing Address (If Different Than Above)
Suite or Floor No.
City
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IA
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WI
WV
WY
PR
VI
Zip Code
4.
*Telephone Number:
Contact Person:
Contact Email:
5.
SIC Code:
6.
Form of Organization
Corporation
Partnership
Sole Proprietor
Other
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
Paper Bill via US Mail
Electronic Bill:
Email:
Name:
Phone:
11.
*Billing Mode
Annually
Quarterly
Monthly
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)
14.
Covered Employers
Name:
Address:
City/State/Zip Code:
Fed ID#:
Billed Separately (Yes/No)
Yes
No
15.
Covered Employees
All eligible under NY State Disability Law
All except the following (class or classes to be excluded, unions, etc.)
16.
Employee Contribution
Contributory
Non-Contributory
17.
Names of Proprietors or Partners to be covered:
Date Employer First Became Proprietor/Partner
Opt IN- DBL&PFL
18.
Other Voluntary
Opt IN-DBL Only
Opt IN-DBL&PFL
19.
Optional Enriched DBL Coverages
A. In-Hospital Supplement
DOUBLE (additional 20% of preminum)
TRIPLE (additional 40% of preminum)
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
Plan A
50% to $200
Plan B
50% to $250
Plan C
50% to $300
Plan D
50% to $350
Plan E
50% to $400
Plan F
50% to $450
Maximum Weekly Benefit
Plan G
50% to $500
Plan H
60% to $200
Plan I
60% to $250
Plan J
60% to $300
Plan K
60% to $350
Custom
% to $
20.
Worker's Compensation Carrier:
21.
Previous Disability Carrier:
22.
Agent or Broker:
23.
SubAgent*:
Address:
Address*
City
City*
State
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IA
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WI
WV
WY
PR
VI
Zip
State*
AK
AL
AR
AZ
CA
CO
CT
DC
DE
FL
GA
HI
ID
IL
IA
IN
KS
KY
LA
MA
MD
ME
MI
MN
MO
MS
MT
NC
ND
NE
NH
NJ
NM
NV
NY
OH
OK
OR
PA
RI
SC
SD
TN
TX
UT
VT
VA
WA
WI
WV
WY
PR
VI
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.
Accepted and Signed at
on this
day of
, 20
Employer
By
Title
Notes: (included in the email)
Submit Application
×
Yes, thanks.
No, just the Disability policy.