Home » Products » DBL and PFL Benefits » NY State Statutory Disability Insurance – Under 50 Lives NY State Statutory Disability Insurance – Under 50 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 NYALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY ZIP Employer Information Employer Name: Address City State NYALAKAZARCACOCTDEDCFLGAHIIDILINIAKSKYLAMEMDMAMIMNMSMOMTNENVNHNJNMNYNCNDOHOKORPARISCSDTNTXUTVTVAWAWVWIWY ZIP Phone Extension Unemployment Insurance Number: Unassigned SSN or Federal Tax ID: Mandatory Form of Organization: —Please choose an option—CorporationPartnershipSole ProprietorshipOther Nature of Business: Number of employees to be insured: Male Female Total Desired Effective Date of Coverage: Previous DBL Carrier: Termination Date: Name of Workers Compensation Carrier: Insurance Company Desired: Standard SecurityWestCoGuardianShelterpoint Additional employees to be Included as covered employees: Remarks: Please confirm: Do you wish to bind coverage? —Please choose an option—YesNo New to this website? We cannot bind coverage for you without a copy of your license. Please fax a copy of your license to us at 631-265-7054. To submit your request, enter the following code into the box below and click the Submit button. To use CAPTCHA, you need Really Simple CAPTCHA plugin installed. Want to know more about DBL insurance? Email us at DBL@victorson.com.