NYS Statutory Disability Benefits Law DBL/PFL Application

I am applying for a NY Statutory Disability Benefits (DBL) and Paid Family Leave (PFL) Policy based on the information I am about to submit. Effective January 1, 2018, DBL comes with a mandatory rider providing NY Paid Family Leave (PFL) coverage for employees. I understand that an underwriter has to review the information submitted before a policy can be issued.
I am aware that other Benefit Options are available.

Cases of 50+ employees cannot be submitted online. Please e-mail Underwriting for a custom quote or submit an RFP online.

(View Underwriting Requirements for groups of 50+)

Application Contact Information

Fields marked with a * are Mandatory

Please enter your contact info below. This information will only be used to inform you of the status of the application, and to deliver the policy kit upon approval.

* First Name

* Last Name

* E-mail

Phone   

Employer Information

*Is your client a public employer?
*Complete Legal Name(as filed with NYS Dept.of Labor)

Name Continued

*Federal ID# (TIN)    
C/O or ATTN

*Mailing Address. ?
*ZIP

*City

*State

*Phone

Fax         

*Nature of Business/Industry Type
*Industry Code
   Search Industry
*Legal Status

*Previous Disability Carrier

Unemployment Insurance#

Current Workers’ Compensation Carrier

Employer Contact Information

First Name

Last Name

Email

Confirm Email


Business Address is different from Mailing address
*Address

*ZIP


*City


*State

Additional Entities/Locations to be covered

Please enter information for each additional entity/Location to be covered. Be sure to click "Add this" for each.

*Complete Legal Name (as filed with NYS Dept.of Labor)

C/O or ATTN
*Federal ID# (TIN)

*Address (Physical Location, not a P.O. Box)

*ZIP

*City

*State

*Legal Status

Unemployment Insurance#


*if added entity is visible below, addition was successful.

Exclusions

Voluntary Coverage Groups           
All employees, pursuant to New York Disability Benefits Law Section 204, are covered. If excluding classes of employees, list below.

Voluntary coverage requires form DB135 or DB136 to be submitted with application unless form is currently on file with the New York State Workers' Compensation Board.

Out-Of-state Coverage Proprietor Coverage

Do you wish to cover out-of-state employees for DBL?

*Coverage not available for employees in states/territories with mandated temporary Disability insurance.

PFL coverage is not available for employees in states/territories other than New York State.
Please name any sole proprietor or partner(s) who desire to be insured.
Enter one name at a time and press the "Add" button for each.
*Name
*Gender
*Title
 

Build your own DBL/PFL and Optional Benefits Package

Policy Information

*Effective Date             

*# of Males

*# of Females

*Billing Mode

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Effective January 1st, 2018, DBL comes with a mandatory rider providing New York Paid Family Leave (PFL) coverage for employees.

DBL/PFL Benefits
*DBL Benefit Level Help
*Statutory Paid Family Leave (PFL) Rider Help

PFL rate is set by New York State at 0.388% of covered wages.

*In-Hospital Rider Help
*AD&D Benefit Rider Help
Optional BaseLine Benefits
*Term Life Help
Optional Non-Insurance Benefits
*Employee Assistance Program Help
*24/7 Nurse HelpLine Help

Estimated Premium not including PFL Premium:    $
PFL Premium: 0.388% of covered wages per NYS*
*(Exact amount to be calculated at time of premium payment.)

Maximum Employee Contribution

The contribution of any employee toward the DBL premium shall not exceed 1/2 of 1% of wages received on and after the effective date of this policy, subject to a maximum of 60 cents per week.


   

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NOTICE (not applicable to Life policy): 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 $5,000 and the stated value of the claim for each such violation.




SPL DB0519 A BL

05/2019