New Jersey TDB (Temporary Disability Benefits) Coverage

Fill out the form below or click here to download PDF version of form.

Full Legal Name of Policyholder – indicate all legal names and Federal Tax ID numbers

Address of Policyholder

City

State

Zip

Current Number of NJ Male Employees*

Current Number of NJ Female Employees*

(*includes part-time and full-time)

Most Recent (5) Years AC 174 Form (Notice of Employer Contribution Rates)

UC 27 Billing Statements
If the policyholder operates with more than one legal name, please provide the above information for each entity.

Special Services

W2 Services
Yes
No

Employer FICA Match Services
Yes
No

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

For Existing Private Plans, provide the last 3 Years, Premium, Claim and Rate History

Period

Premium

Claims

Rate/Carrier

Period

Premium

Claims

Rate/Carrier

Period

Premium

Claims

Rate/Carrier

Broker Information

Broker/Consultant Name

Company

Email Address

Phone Number

Your client has a policy already? Let our experts take a look (call us or submit a copy of the policy).
Please note that coverage cannot be bound via online submission.