Business Information

Business Name:

Premises Address:

City:

State:

Zip Code:

Years In Business:

Contact Name:

Phone:

Extension #:


Email:  (Required)


How Best To Contact You:


Federal Employer's ID #:

Description of Operations:


Number of Employees to be Insured:




Insurance Information

Currently Insured:


Insurance Expiration:

Any losses past 3 years?


Description of losses, including
amount paid on each accident.




Coverage Information

Who Will Be Insured:


Amount of Coverage Per Employee:


Other Insurance Amount Desired:




Has anyone to be insured
had health problems during the
past 3 years:


If Yes, list information:


Anyone to be insured
have a hazardous job:


If Yes, how many with hazardous jobs:


Anyone to be insured an active
member of the military reserves:


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




Question or Message:



Click the "Submit Quote Request"
button below to send your New York
Group Life 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
life 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, New York.
Group Life
Insurance Quote
Direct Access Group Benefits, Inc.
© 2004, All Rights Reserved
914-276-6000
800-498-1819
Westchester County New York Insurance Agency