Business Information

Business Name:

Premises Address:

City:

State:

Zip Code:

Years In Business:

Contact Name:

Phone:

Extension #:


Email:  (Required)


How Best To Contact You:
Select One Phone Email

Federal Employer's ID #:

Description of Operations:




Any Employees Currently Insured:
Select One Yes No



Coverage Information

Who Will Be Insured:
Select One All Employees Some Employees Management Only Owners Only


Number of Employees to be Insured:
Select One 1 to 5 6 to 20 21 to 50 51 to 100 More Than 100


Length of Group Disability
Coverage Needed:
Select One NY State Mandated Coverage Short Term (Less than 4 months) Long Term (More than 4 months) Both Short & Long Term


Type of Group Disability
Coverage Needed:
Select One Accident Only Health Only Accident & Health


Monthly Benefit Amount For
Each Person Insured:
Select One NY State Mandated Amount 50% of Salary 66% of Salary 100% of Salary Other Amount


Benefit Period Desired For
Each Person Insured:
Select One NY State Mandated Period 13 weeks (Short Term Policy) 17 weeks (Short Term Policy) 6 months (Long Term Policy) 6 mths to 2 yrs (Long Term Policy) 6 mths to 5 yrs (Long Term Policy) To Age 65 (Long Term Policy)


Elimination Period Desired For
Each Person Insured:
Select One NY State Mandated Period None 30 days 60 days 90 days 180 days


Payment Mode:
Select One Annual Semi-Annual Quarterly Monthly



Anyone to be insured
have a hazardous job:
Select One Yes No

If Yes, how many with hazardous jobs:


Anyone to be insured an active
member of the military reserves:
Select One Yes No

If Yes, how many are members
of the military reserves:




Explain any recent Workers
Compensation claims:




Question or Message:



Click the "Submit Quote Request"
button below to send your New York
Group Disability Insurance request
to Direct Access Group Benefits.


***By submitting this request you
acknowledge that this is neither
an offer to insure nor a guarantee
of insurance.***

We are a Somers, NY insurance
agency offering New York group
disability insurance quotes in the
following towns, cities and counties
in the Westchester County, NY area:
Port Chester, Harrison, Mamaroneck,
Larchmont, New Rochelle, Yonkers,
White Plains, Rye Brook, Scarsdale,
Rye, Ardsley, Hartsdale, Bronxville,
Mount Vernon, Irvington, Valhalla,
Elmsford, Dobbs Ferry, Hastings
on Hudson, Greenburgh, Tarrytown,
Sleepy Hollow, Hawthorne,
Scarborough, Thornwood, Briarcliff
Manor, Ossining, Harmon, Montrose
Crugers, Buchanan, Peekskill, Millwood,
Pleasantville Armonk, Chappaqua, North
Castle, Mt. Kisco, Bedford, Pound Ridge,
Bedford Hills, Cross River, South Salem,
Yorktown Heights, Goldens Bridge,
Amawalk, Yorktown, Katonah, Salem
Center, Somers, North Salem, Croton
Falls, Jefferson Valley, Shrub Oak,
Palisades, Sparkill, Tappan, Orangeburg,
Pearl River, West Nyack, New City,
Nanuet, Chestnut Ridge, Montebello,
Suffern, Monsey, Spring Valley, Congers,
Nyack, Rockland Lake, Wesley Hills,
New Hempstead, Pomona, Sloatsburg,
Ramapo, Hilburn, Willow Grove, Mt. Ivy,
Thiells, Tomkins Cove, Ladentown,
Haverstraw, Stony Point, Tomkins Cove,
West Haverstraw, Bear Mountain, Jones
Point, Newburgh, Middletown, Bronx,
New York City, Brewster, Poughkeepsie,
Putnam County, Orange County, and
Rockland County, NY.



Direct Access Group Benefits, Inc.
189 Route 100, PO Box 590
Somers, NY 10589
Westchester County, New York

Group Disability Insurance Quote Westchester County, NY

Direct Access Group Benefits, Inc.
© 2004, All Rights Reserved