Untitled Document

Frank Cafaro
26 Railroad Avenue #300
Babylon, New York 11702
office phone: 631-321-6165
cell phone: 516-480-2396
fax: 631-321-6175
Email: info@cafaroinsurance.com

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Cafaro Group Disability Quote Form

Disability Benefits Law

Enacted in 1949 in New York State if you are an employer and employ 1 or more employees for a least 30 work days in any calendar year you are required to obtain coverage (with few exceptions). DBL Benefit 50% of average weekly wages, maximum $170, with a 26 week maximum benefit per 52 weeks and a 7 day wait for accident & sickness.

Please fill in all question fields in order for us to give you the most accurate quote possible. Also, please provide a valid phone number. Insurance Quote Forms without phone numbers will not be quoted.

Your Name:
Phone Number:
Fed Tax ID:
Unemployment Insurance #:
Complete Legal Business Name:
Address:
State:	Zip:
Nature of Business:
Type of Organization:
Number of Males / Females:	Males Females
Desired Effective Date:
In Force Carrier:
Questions/Comments:

Thank you for taking the time to answer the questions in this request form. I understand that this service merely provides a proposal request and is not a Policy of Insurance, Application or Offer to Insure on behalf of any Insurance Company, Agency or Agent. Individual companies reserve the right to accept, reject or modify a proposal after investigation and review.