STANDARD SECURITY LIFE INSURANCE COMPANY OF NEW YORK

NEW YORK DISABILITY BENEFITS, PAID FAMILY LEAVE INSURANCE, & GROUP LIFE APPLICATION

The undersigned employer hereby applies for a policy of group insurance. No insurance shall be binding unless and until
this application is approved by Standard Security Life Insurance Company of New York (SSL). Paid Family Leave coverage (PFL) is
provided at the benefit amounts and duration required under WCL §204(2). PFL does not cover out of state employees.

*Required
Employer Informtion:
1. *Full Legal Name of Employer:
Doing Business as Name: (if applicable)
2. *Physical Address: Suite or Floor No.:        
*City: *State: *Zip Code:
3. Mailing Address: Suite or Floor No.:        
City: State: Zip Code:  
4. *Telephone Number: Contact Person:
Contact Email: 5. Type of Business:  
Nature of Business or SIC Code
6. Form of Organization:
7. NY Employer Registration (UI) #: 8. *Federal Taxpayer ID #:
9. *Requested Effective Date: (Note: Workers' Compensation Board requires receipt within (30) days)
Billing Informtion:
10. *Billing Delivery Mode:
Email:
Note: Please consider email option, as it allows delivery to multiple copies. Name:
Phone:
11. *Billing Mode:
12. *No. of Employees to be Insured:      DBL Male: Female: TOTAL DBL:
PFL Male: Female: TOTAL PFL:
13. DBL Groups of 50 or More Lives (rates require prior approval by underwriter)
DBL:
Male $ Female $
     
Per $100 of Covered Payroll (maximum $340 per week)
Additional Covered Legal Name/FEIN or Location(use an extra sheet of paper if necessary):
14.  Name: Address: City/State/Zip Code: Fed ID#: Billed Separately (Yes/No)





15. Covered Employees

16. Employee Contribution
Voluntary Coverages
If voluntary coverage is elected by a sole proprietor (SP), a member of a limited liability company (LLC), a member of a limited liability partnership (LLP) or other self-employed person (SEP), SSL shall subject the applicant to a waiting period of 2 years before benefits are payable, unless the policy is issued within 26 weeks of when the employer first becomes a sole proprietor (SP), LLC, LLP, or other SEP. An SP with employees, a member of an LLC with employees, a member of an LLP with employees or other SEP with employees, shall be covered under the same policy that cover’s the policyholder’s employees.
17. Names of Proprietors/Partners to be covered: Date Employer First Became Proprietor/Partner
a)   
b)   
Note - Please mark this option if you desire to have the above-mentioned name(s) covered for DBL & PFL.
18. Other Voluntary
a)   
b)   
19. Optional Enriched DBL Coverages          
A. In-Hospital Supplement
B. DBL Enriched Benefit - The following plans apply to groups with 1-49 lives only. Custom enriched plans for groups with 50+ lives are available with underwriting approval.
Maximum Weekly Benefit
50% to $200 50% to $350 50% to $500 60% to $300
50% to $250 50% to $400 60% to $200 60% to $350
50% to $300 50% to $450 60% to $250  % to $ 

20. Optional Benefit: Guaranteed Issue Group Term Life Insurance - NY Employees Only (choose one option only):
21. Worker's Compensation Carrier:
22. Previous Disability Carrier:
23. *Agent or Broker: *Code #
Address:
City: State Zip
23. SubAgent*: Code #
Address*
City* State* Zip*
Email: *
NOTICE - 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 stated value of the claims for each such violation. (PLEASE NOTE - This is not applicable to the life insurance coverage.)
*Signed at: this day of , 20
*Employer:
           *By:          Title:
NYDBL-PFL-GTL-APP-00-Rev. (1-24)
 
By completing the application and checking the box above, you do hereby attest that: 1) you are the individual named above 2) you are duly authorized to execute this application on behalf of the employer named on this application 3) you are authorized to receive and have permission from the employer name on this application to receive documents electronically, including policy and certificate documents and 4) you have reviewed and approved the information within the application to be true, accurate and complete to the best of your knowledge.
Notes: (included in the email)



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