Business DBL Application

BUSINESS DBL APPLICATION

Parties & Recitals

WHEREAS, Applicant Name: (hereinafter "Applicant"), is an employer seeking to obtain group disability benefits coverage for eligible employees; and

WHEREAS, Provider Name: (hereinafter "Provider"), is authorized to underwrite, administer and provide Disability Benefits Law (DBL) coverage and related services under the terms and conditions set forth herein; and

NOW, THEREFORE, in consideration of the mutual covenants and agreements contained in this Application and Agreement, the parties agree as follows and Applicant requests issuance of DBL coverage in accordance with the information provided.

Applicant Information

Corporation    LLC    Partnership    Sole Proprietor

Coverage Requested

Proposed Effective Date:

Plan Option Requested:    Standard DBL    Enhanced DBL with Additional Benefits

Scope of Work

The Provider shall provide DBL policy administration services, claims adjudication, benefit payments described under the selected plan option and employer reporting requirements as required by applicable law. Applicant requests issuance of coverage for the eligible employees set forth in this application and agrees to remit premiums as set forth herein.

Payment Terms

Applicant shall pay all premiums, fees and assessments due under any policy issued in reliance on this Application. Premium calculation, adjustments and audits shall be performed in accordance with Provider underwriting rules. Failure to pay amounts when due constitutes a material breach and may result in suspension or cancellation of coverage.

Monthly    Quarterly    Annual

Percentage   %    Flat Fee  

Term and Termination

This Agreement shall commence on Start Date: and continue until End Date: unless earlier terminated in accordance with this Agreement.

Either party may terminate for material breach where the breaching party fails to cure within the notice period specified above. Provider may terminate or suspend coverage for nonpayment of premium after notice in accordance with applicable law.

Confidentiality

Each party shall maintain in confidence all non-public business, employee and claims information received in connection with this Application and any policy issued hereunder. Confidential information shall not be disclosed except as required by law or with the prior written consent of the disclosing party. This obligation survives termination of the Agreement for a period of three (3) years.

Applicant acknowledges that medical and disability-related employee information is protected and will be handled in compliance with applicable privacy laws.

Applicant acknowledges and agrees to the Confidentiality obligations set forth above.

Representations; Certifications

Applicant represents and certifies that all information provided in this Application is true, accurate and complete to the best of Applicant’s knowledge. Applicant authorizes Provider to verify payroll, employment and claim information with third parties as necessary for underwriting, premium calculation and claims administration.

Governing Law

This Application and any policy issued pursuant to it shall be governed by and construed in accordance with the laws of the State of , without regard to conflict of law principles.

Entire Agreement

This Application, together with any schedules, endorsements or policy documents issued by Provider, constitutes the entire agreement between the parties regarding the subject matter hereof and supersedes all prior negotiations, proposals and representations, whether written or oral. Any amendment or modification must be in writing and signed by both parties.

Additional Information

By signing below, Applicant warrants that the signatory is authorized to bind the Applicant to the terms of this Application and Agreement and requests that Provider issue the requested DBL coverage in reliance on the representations and information contained herein.

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