NYS Disability Insurance in the Hudson Valley
877-EZDBL-80



877-393-2580  
 
   NY State Disability Benefits Law (DBL) Insurance  
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APPLICATION FOR NEW YORK STATE DISABILITY BENEFITS POLICY

Affordable New York State Disability Insurance

The undersigned employer hereby applies for a policy of group insurance to provide benefits in accordance with Section 204 of the New York Disability Benefits Law, to be used in reliance on the statements made in this application. No insurance shall be binding unless and until this application is approved at the Home Office of the Company.

   
Employer
Business Address
Suite or Floor
City
State
ZIP
   
Billing Address (if different)
Suite or Floor
City
State
ZIP
   
Phone
Contact Person
Email
Nature of Business
Form of Organization Corporation Partnership Sole Proprietor Other
NY Employer (UI) #
Federal Taxpayer ID #
Effective Coverage Date
Billing Method Paper Electronic (please provide email address)
Billing Interval Annual Quarterly Monthly
# of insured employees Male Female
Names of Proprietors or Partners (optional)
Please note that proprietor and partner rates are higher than employees and a separate application may be needed . Corporate officers receive employee rate.
Covered EMPLOYERS (Names of businesses with same ownership to be insured)
Name Address Federal ID # Billed separately Yes No
Name Address Federal ID # Billed separately Yes No
Name Address Federal ID # Billed separately Yes No
Name Address Federal ID # Billed separately Yes No
Covered Employees All eligible under NYS Disability Law All except the following classes
Employee Contribution Contributory Non-contributory
Workers Comp Carrier
Previous Disability Carrier
"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 five thousand dollars and the state value of the claim for each such violation."

By checking the box below, I do hereby attest that:
1) I am the individual whose name appears below
2) I am duly authorized to execute this application
3) I am executing this application on behalf of the Employer named below
4) I have reviewed and approved the information contained herein and the information is true, accurate and complete to the best of my knowledge
Accepted at: on
Employer By Title
Message or addtional information:
Enter security code
Ryan and Ryan Insurance Brokers, Inc. dba EZDBL
400 Stockade Drive - Kingston, NY 12401
(877) EZDBL-80 (845) 340-0001
© 2015


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