DBL Questionnaire – 50 Lives & Over

Employer Name

NY Location Address

Contact Name

Email Address

Telephone Number

Billing Address

City

Federal Tax ID

N.Y. Unemployment Ins#

Nature of Business

4-Digit SIC Code

Contributions (Max Contribution is $.60 per Week)
Yes
No

Requested Effective Date

For Policyholders that are an LLC, or LLP, please indicate if coverage for Partners is desired.
If yes, we will need Name, D/O/B & Social Security # for All Partners, Proprietors to be covered.
Yes
No

Names of any Subsidiaries or Participating Firms (if any)

(Indicate Full Legal Name, FED ID #, NY UI # and # of Employees for Each Subsidiary)

Special Services

W2 Services
Yes
No

Employer FICA Match Services
Yes
No

Out of State Coverage
(List # of Male and Females by State)