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
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