NY State Statutory Disability Insurance – Groups of 50 or More Lives

To apply for coverage, please complete and submit the application below.

Fields indicated with an asterisk * are required.

Broker Submitting Quote Request
  Licensed YesNo
  Agent ID
* First Name
* Last Name
  Company
* Phone
Extension
* Email
  Fax
  Address
   
  City
* State
  ZIP
Employer Information
  Employer Name: 
  Address
   
  City
  State
  ZIP
  Phone
  Extension
  Unemployment Insurance Number:

Unassigned
  SSN or Federal Tax ID:

Mandatory
  Form of Organization: 
  Number of employees to be insured:
  Male
  Female
  Total
  Desired Effective Date of Coverage: 
  Previous DBL Carrier: 
  Termination Date: 
  Name of Workers Compensation Carrier: 
  Additional employees to be included as covered employees:
  Are you the broker on this line now? 
  How do you wish to have your proposal sent to you? EmailFaxPhone
 
To submit your request, enter the following code into the box below and click the Submit button.

captcha


In addition to completing the above application, please fax to us:

  • A copy of a recent bill.
  • Loss experience for the last three years, if possible.

Our fax number is 631-265-7054.


Want to know more about DBL insurance? Email us at DBL@victorson.com.