A RELIANCE STANDARD COMPANY

Home Office: 488 Madison Avenue. New York, New York 10022. 212-355-4141
Website: https://sslicnj.com   E-mail:njtdbunderwriting@sslicny.com
REQUEST FOR NEW JERSEY TEMPORARY DISABILITY BENEFITS POLICY
Requested Effective Date of Coverage(mm/dd/yyyy): *
Employer:*
dba t/a a/k/a other:
Address:*
City:*
State:*   Zip: *   Phone:
Employer Identification
Number (EIN):		*
Authorized Representative:
Title:
Phone:
EMail:
Address: (if different)
City:
State:   Zip:
Nature of Business:
Number of Employees to be Covered:   Males *  Females *  Non-binary
Classes of Employees to be Covered:     All
ALL Employees of the Employer EXCEPT:
ClassState Plan or
Private Plan		No. of Employees
** No class of employee can be excluded based on age, race, sex, national origin or wages paid, which will result in adverse selection. DP-1-A is required for excluded class(es).
Employee Contributions:    Contributory     Non-Contributory (Employer pays 100% of coverage including employee contribution)
Percentage of Benefit That is Taxable (.01-100 or leave blank if unknown): (This will be needed before claims can be paid.)
Schedule of Benefits:Premium Basis:
Statutory    Non-Statutory
 Wages    Per Capita     Other
(If benefits are better than statutory, please define below.)
Weekly BenefitWaiting PeriodMaximum Duration
% of Average Weekly Wages to a
Maximum of $		 Accident: days
Sickness: days		 Weeks
SSL Broker #:
*
*** (Note: Broker must have a New Jersey's broker or life and health license.)		SSL General Agent #:
Broker Name:*General Agent:
Broker Address:GA Address:
Broker City:GA City:
Broker State:  Zip: GA State:  GA Zip:
Additional Employers to be Included. List Below Those Employers Affiliated with Policyholder by Financial Interest or Control, Whose Employees are to be Covered Under This Policy. Name of Group/Entity and Address with City, State, Zip and Tax ID # (1 group/line).
Optional - Additional Policy Contact and Service Requests:
Billing Contact: Billing E-mail:
Payroll Contact: Payroll E-mail:
HR Contact: HR E-mail:
Employer FICA Match Service?No Yes   
FICA Report FrequencyQuarterly Monthly Both How Are Bills to be Sent? Paper Email

Signed: (a broker can sign for an employer online)
Name:*
Title:*
Telephone #:*
Email:*
Special instructions:

* REQUIRED FIELDS!

Add Attachments (DP1, DP1A, FICA reports, loss run, NJ-927s, premium report or other outstanding underwriting requirements from proposal. If the broker is new to Standard Security Life's NJ TDB program, a copy of their license and W-9 should be included. In the alternative, documents can be mailed to njtdbunderwriting@sslicny.com.)



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