No Obligation Quote Request Form
Employer Legal Name
Employer Address
Business Phone No.
Current DBL Carrier
Please enter the text shown in the image into the field below.
Protection Code
(New York State Residents Only)
NY State Disability Benefits (DBL) Insurance
Applications are subject to Insurance Company approval.

Completion of the above form will secure details, but does not bind or modify coverage.
Policy Renewal Date
Non-Renewal Date
Reason
Federal Employee ID# (FEIN)
Employer is:
A.
Corporation (PC)
S_Corp
As of current date, total employee count including all full-time and part-time employees except high school students
is as follows
# Males
# Females
Please include in the above count any executive officers of the corporation who wish to be covered under this policy.
Corporations with three or more executive officers must include all officers in the above counts. If you
have questions regarding who is required to have coverage or who can be excluded, please call our office.
OR
B.
Partnership
Sole Proprietor
PLLC
As of current date, total employee count including all full-time and part-time employees except high school students is
as follows:
# Males
# Females
# Partners & Proprietors/Members (Optional)
Loss History for past three (3) Years
Policy Year
Carrier
# Claims
Amount Claims Paid
Individual Completing this Form
LLC
PLLP
LLP

 

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