4.03 4.3
INSURANCE\NYS Disability Income Replacement—Lincoln Financial—6-13-2022
RESOLUTION AUTHORIZING MARSHALL & STERLING UPSTATE,
INC., TO INSURE THE TOWN OF QUEENSBURY'S
NEW YORK STATE DISABILITY INCOME REPLACEMENT INSURANCE
WITH LINCOLN FINANCIAL GROUP
RESOLUTION NO.: ,2022
INTRODUCED BY:
WHO MOVED ITS ADOPTION
SECONDED BY:
WHEREAS, Marshall & Sterling Upstate, Inc., (Marshall & Sterling) is the Town of
Queensbury's general insurance agent and as such solicited for quotations from insurers for the Town's
New York State Disability Coverage, and
WHEREAS, Marshall & Sterling has advised that Lincoln Financial Group submitted the
lowest responsible proposal, and
WHEREAS, the Town Board wishes to therefore authorize the insuring of the Town's New
York State disability income replacement insurance with Lincoln Financial Group effective July 1, 2022
as set forth in Lincoln Financial Group's Proposal substantially in the form presented at this meeting,
NOW, THEREFORE, BE IT
RESOLVED, that the Queensbury Town Board hereby authorizes Marshall & Sterling
Upstate, Inc., to insure the Town of Queensbury's New York State disability income replacement
insurance with Lincoln Financial Group effective July 1, 2022 in accordance with Lincoln Financial
Group's Proposal substantially in the form presented at this meeting, and
BE IT FURTHER,
RESOLVED, that the Town Board further authorizes and directs the Town Supervisor and/or
Town Budget Officer to execute any documentation and take any actions necessary to effectuate the
terms of this Resolution.
Duly adopted this 13t'day of June, 2022,by the following vote:
AYES
NOES
ABSENT:
Proposalprepared for:
Town of Queensbury
Presented to: !
EMERSON REID LLC iw
Prepared by:
Andrea Patterson
Andrea.Patterson@Ifg.com
(973)549-7417 .
Proposal valid through:August 17, 2a22
I"
Situs state: New York -�
Products:
New York Disability Benefits Law(DBL), New York Paid
Family Leave(PFL)
Insurance products issued by:
Lincoln Life&Annuity Company of New York
Quote ID:87011
8
Welcome................................................................................................................................1
Costsummary........................................................................................................................3
Considerations.......................................................................................................................4
New York Disability Benefits Law (DBL).................................................................................5
New York Paid Family Leave (PFL)......................................................................................... 7
Proposaldisclaimer............................................................................................................... 9
PrivacyNotice......................................................................................................................10
Quote ID:87011
-
�
We're pleased to meet you.
And we'd like to let you know how we"
do things -usta little differently at Lincoln.
After a century or so,you learn a thing ortwo.
You learn that integrity is more than a nice word to usewith your customers.You learn that trust is something you continuously
earn.You learn that value isn't always measured in dollars and cents.
And you learn that the key difference between one carrier and another often isn't the product itself. It's the personal
commitment a company shows toward its customers,the flexibility that lets us deliver the right plan for each company, and
the daily interactions that add up to the kind of experience you can count on when you work with Lincoln.
For more than 110yeana, Lincoln Financial Group has been dedicated to delivering the flexible solutions and customer
support needed at some of the most challenging times in a person's life.We promise to be there when our customers need
us, giving them the tools and information they require to confidently select, use and administer their benefits.And we work
closely with our customers to develop solutions that not only meet immediate needs but also recognize future developments
and concerns.
/n short,me promise tadn the right thing.
Doing the right thing for our customers
VVe know that employers aren't looking for cookie-cutter coverage Withimpersonal service. Companies put their
reputations on the line when they select a carrier to provide benefits for their employees.A carrier's actions—and
inactions--can reflect directly on the company that made the choice.
That's why Lincoln is committed to working as an ally to each of our employer groups, focusing on what benefits each
company and its employees need to grow and thrive.
Quote ID:87O11
�
Doing the right thing for employees Who depend on our coverage
Of course,strong relationships with our customers are essential. But in the end,it comes down to results. Did our
coverage make a difference in the lives of employees?Can they depend on Lincoln when it matters most? Here are just a
few of the ways how and how many people were helped by Lincoln group benefits:'
226,492
r
disabled
%
individuals
CID
who enjoyed time off whose lives we helped get whose smiles we enhanced by
with their babies back on track and who we helping parents fund braces
helped regain
the ability to work
7533
�omwp=owv people
�1111N 25 5 05 who made trips to the ER for
which we helped cover immediate
VI11l1ll1iI beneficiaries "accidental"expenses
who lost a loved one
Doing the right thing for the future
We're making sure our customer-oriented approach continues to meet your expectations, by making strategic clinical and
technical investments and taking the proactive steps necessary to ensure our infrastructure will always be ready and able
to:
Anticipate future challenges and support our customers with purpose-built employee benefit solutions
Deliver quick and accurate implementation and enrollment for every size workforce
Meet specific plan-design requests that fit a company's needs and budget
Offer robust self-service capabilities that help employees easily manage their benefits
We've got your back
We are honored to be number 188 on the 2020 Fortune 500 list.As one of the nation's leading group disability insurers,we
offer broad, flexible group benefits portfolios including total absence management services, as well as life, dental, vision,
accident and critical illness protection.2 Our sound and secure past and sharp eye toward the future mean that we'll be there
when you need us—a trusted partner always ready to back up our promises with performance.3
We welcome the opportunity to meet,to further discuss the contents of this proposal and to explore how together, we can
help you reach your employee benefit goals.
12020 claims.
22019 LIMRA ratings for Annuities,Life Insurance,Retirement Plan Services and Group Protection.
3Guarantees are subject to the claims-paying ability of the issuing company.
Quote ID:87011 2
D
Option 1 Class. 1
-Rate guarantee: .24 months iCovered employees. 164 T _
'Effective date: 07/01/2022 Monthly rate: $0.197/per$100 covered
monthly payroll
Volume: 241,627 per$100 covered
I monthly payroll(Female=
81,033 per$100 covered
monthly payroll and Male=
i 160,593 per$100 covered
monthly payroll
'Estimated premium: $5,712.12
Option: Class: 1
!Rate guarantee: ]24 months jCovered employees: Male:109
Female:55
Total:164
.._.._._.._.._-.---
!Effective date: 107/01/2022 ;Monthly rate: $0.511/per$100 of wages up to
$82,918
_ IVolume: Determined when census
provided
Estimated premium: Determined when census
provided
See rate section for specific rate information
Quote ID:87011
3
,
,
General Considerations:
Please note that Lincoln Financial Group's quote assumes plan design as outlined in this proposal for all coverages.While It is our intent
to match the current and requested provisions as closely as possible and within our underwriting guidelines,there may be contractual
differences between the incumbent carrier's policy and our proposed policy. Lincoln Financial Group's state-filed and approved verbiage
will prevail.
Rates premiums,and fees shown in this proposal were based on the proposed plan of benefits and census information provided.We
reserve the right to reevaluate pnnposal terms, rates and conditions should the effective dame change. We also reserve the right to
change rates and premiums if on the effective date or at any time during the policy year:
° The number oflives/volume changes by more than+/-15%
° The plan benefits change
° A division,associated company,or affiliate is added or deleted from this group;or,
° The requested level of service changes
Please note that rates in proposal are based on packaged pricing. If any quoted product in this proposal does not sell,we reserve the
right to modify rates and issue a new proposal.
`
Quote ID:8Tozz
4
~
�
Lincoln offers fully compliant New York Disability Benefits Law/DBUto help employers satisfy the New York statutory
coverage requirement.We provide one policy inclusive of statutory disability and paid family leave coverages—both
required in New York. Lincoln coordinates claim administration for NY PFL, NY DBL and applicable Lincoln absence
management programs, providing a streamlined experience for each organization and their employees.We work closely
with employers and claimants to ensure they will experience smooth and expert service,from implementation and claim
intake to reporting and customer support.
Product conditions
^ New York DBL must be issued alongside a fully insured core line of coverage(STD, LTD, Life,etc.)
^ New York PFLisa rider to the New York DBLpolicy
° Employee eligibility isbased on New York D8Lrequirements
Class and eligibility descriptions
Option
Class 1
Class description All NowYork Employees
Minimum hours Per New
' York Regulations
� �
New York Disability Benefits Law (DBL) benefit overview
This coverage provides partial wage replacement if an employee is disabled aaa result ofa sickness orinjury.
Option
Class 1
Class description All New York Employees
Coverage amount Weekly benefit 5O%
Maximum coverage amount $170
DuybooaRtbegins—oncidontu|iniury 8mday
Daybenefitbegins—siokness 8mday
Maximum benefit period 26wmako
FICA match Not included
Paid Family Leave(PFL) . Included
Definition ufearnings Per New York Regulations
This im not an exact list;additional benefits may bm found in the policy.
Quote ID:87011
New York Disability Benefits Law(D13L) rates
C7ption: 1 Class: 11
Rate guarantee: 24 months :Covered employees: 164
Effective date: �07/01t2022 'Monthly rate: $0.197/per$100 covered
!monthly payroll
'Volume: 241,627 per$100 covered
monthly payroll(Female=
81,033 per$100 covered
monthly payroll and Male=
i160,593 per$100 covered
(monthly payroll
Estimated premium: $5,712.12
The above rate assumes the Policyholder is responsible for paying the employer's share of Social Security and Medicare(FICA)talc.
Key coverage highlights
• Benefits are administered fully in adherence with NY DBL law and regulations.
• Employers are eligible to receive reimbursement of payable NY DBL benefits if claimant is receiving wage continuation
via a salary continuance or company paid leave program.
• Standard operational reporting available to employers.
Limitations and exclusions
This NY DBL policy will not issue payments if an employee is not under the care of a duly-licensed health care provider, or
on any day the employee performs work for remuneration or profit. Furthermore, no benefit will be payable to an employee
for an Injury or Sickness that results from willful intention to bring about Injury or Sickness to themselves or another,
participation in the perpetration of an illegal act or any act of war,declared or undeclared.
This is not a complete list;additional limitations and exclusions may be found in the policy.
Quote ID:87011
6
,
�
Lincoln offers fully compliant New York Paid Family Leave(PFL)to help employers satisfy their statutory coverage
requirement.This leave benefit allows eligible employees paid time off for child bonding, to care for aD eligible family
member with a serious health condition,or when a family member is called into active military duty. Lincoln coordinates
claim administration for NY PFL, NY DBL and applicable Lincoln absence management programs, providing a streamlined
experience for each organization and their employees.
Product conditions
~ New York PFLis a rider to New York DBL'.|t cannot be issued onm standalone basis.
^ Premium rates and benefits are subject to change each January 1st as stipulated by the state of New York.
^ Employee eligibility im based on New York PFL requirements.
New York Paid Family Leave benefit overview
This coverage provides benefits if an employee is on leave for an eligible reason as stipulated by the New York PFL law.
Option I
Class 1
Class description All NewYnrkEmpk�ees
.
Coverage amount U7Y6ofanmmp|oye��weeWy wages upVo the 2O22S/�VvV°
maximum coverage amount $1.068.36
Day benefit begins 1st day
Maximum benefit period 12weoko
FICA match Not applicable
Definition ofEarnings Per New York Regulations
*Statewide average weekly wage(S —
This ionot an exact list;additional benefits may be found io the policy.
Quote ID:VTu11
7
New York Paid Family Leave rates
;'Option: +~11 Klass: 11
`Rate guarantee*: 24 months Covered employees: 1Male,109 I
Female:55
'Total'164
(Effective date: 07/01/2022 .Monthly rate: $0.5111 per$100 of wages up to1
I$82,918
;volume: Determined when census
provided
:Estimated premium: Determined when census
provided
NY-PFL-Benefits are Taxable non-wage income NOT subject to FICA.
*PFL rate is state mandated and is subject to change each January 1st.
Key coverage highlights
• Benefits are administered fully in adherence with NY PFL law and regulations.
• Employers are eligible to receive reimbursement of payable NY PFL benefits if claimant is receiving wage continuation
via a salary continuance or company paid leave program or during periods an employee is receiving vacation pay for
their full wages.
• Standard operational reporting available to employers.
Limitations and exclusions
This NY PFL policy rider will not issue payments during periods an employee is receiving NY DBL benefits,for any day
the employee performs work for remuneration or profit for your company or for family leave that commenced before the
employee became eligible for benefits.
This is not a complete list; additional limitations and exclusions may be found in the policy.
Quote ID:87011
8
r'
a 0 0 0 0
THIS IS NOT A CONTRACT:This proposal was prepared based on the information provided in the Request
for Proposal and/or through other discussions with the Broker. It is a description of administrative services and/
or insurance. Insurance and/or administrative services available from Lincoln Financial Group are not offers to
contract. More detailed information regarding insurance is available upon request concerning the term,conditions,
and limitations contained in the master policy, if issued.
If there are discrepancies between the information contained in this proposal and the master insurance policy,
the terms of the master insurance policy will control.State-specific restrictions and requirements may not be
addressed in this proposal.
An Application for Group Insurance must be completed by the employer and approved by Lincoln Financial Group
before insurance can become effective.
This proposal is subject to revision if not accepted on or before the proposed valid through date shown on the
cover page of this proposal.
This proposal is written under the assumption that the coverage would be part of the employer's benefit package
for employees and would be subject to the applicable rules under the Employee Retirement and Income Security
Act.
Guarantees are subject to the claims-paying ability of the issuing company.
In New York, insurance products(policy series NYDBL) are issued by Lincoln Life&Annuity Company of New
York(Syracuse, NY). Product availability and/or features may vary by state. Limitations and exclusions apply.
Lincoln Financial Group is the marketing name for Lincoln.National Corporation and its affiliates.Affiliates are
separately responsible for their own financial and contractual obligations.
LCN-2949588-021220
Quote ID:87011
9
'
� Lincoln ��~|1El��'�J ����Un0� �� ��r����6�� KJnf�~�
��l�}{�{��� u . Financial/^^^ ~~ r", Privacy Practices ."`'^.=`~
|� ~�F-i C_,,�up
The Lincoln Financial Group companies*are committed Vo protecting your privacy.Tb provide the products and services you expect
from a financial services leader, we must collect personal information about you. We do not sell your personal information to third
parties.This Notice describes our current privacy practices.While your relationship with us continues,we will update and send our
Privacy Practices Notice as required by law. Even after that relationship ends,we will continue to protect your personal information.
You do not need to take any action because of this Notice, but you do have certain rights as described below.
We are committed to the responsible use ofinformation and protecting individual privacy rights. Assuch, we look to leading data
protection standards to guide our privacy program.These standards include collecting data through fair and lawful means, such am
obtaining your consent when appropriate.
-/
�nfoKmation We May Collect And Use
We collect personal information about you to help us identify you as a consumer, our customer or our former customer;to process
your requests and transactions;to offer investment or insurance services to you;to pay your claim;to analyze in order to enhance
our products and services;to tell you about our products or services we believe you may want and use; and as otherwise permitted
by law. The type of personal information we collect depends on your relationship and on the products or services you request and
may include the following:
^ Information from you:When you submit your application or other forms,you give us information such as your name,address,
Social Security number; and your finnncia|. health,and employment history.VVa may also collect voice recordings orbiomet,ic
data for use in accordance with applicable|avu
^ Information about your transactions:We maintain information about your transactions with us,such as the products you buy
from us;the amount you paid for those products;your account balances;payment details;and your payment and claims histor�
^ Information from outside our family of companies:If you are applying for or purchasing insurance products,we may collect
information from consumer reporting agencies,such as your credit history;credit scores; and driving and employment records.
With your authorization,we may also collect information,(such as medical information, retirement information,and information
related to Social Security benafita).from other individuals orbusinesses.
^ Information from your employer:If your employer applies for or purchases group products from us,we may obtain information
about you from your employer or group representative in order to enroll you in the plan.
How We Use Your Personal Information
We may share your personal information within our companies and with certain service providers. They use this information to
process transacfions you, your employer,or your group representative have requested;to provide customer service;to analyze in
order to evaluate oc enhance our products and services;to gain customer insight;tV provideeducation and training to our workforce
and customers;and to inform you of products or services we offer that you may find useful.Our service providers may or may not be
affiliated with us.They include financial service providers(for example,third party administrators; broker-dealers;insurance agents
and brnkoro, registered representatives; reinsurers and other financial services companies with whom we have joint marketing
agreements), Our service providers also include non-financial companies and individuals(for example, consultants;vendors; and
companies that perform marketing services on our beh8|o. Information vm*obtain from a report prepared bya service provider may
be kept by the service provider and shared with other persons; however,we require our service providers to protect your personal
information and to use or disclose it only forthe work they are performing for us,or as permitted by law.We may execute agreements
with our service providers that permit the service provider to process your personal information outside of the United States,when
not prohibited by our contracts and permitted by applicable law.
When you apply for one of our products, we may share information about your application with credit bureaus. We also may
provide information to group policy owners or their designees(for example,to your employer for employer-sponsored plans and their
authorized service providers), regulatory authorities and law enforcement officials, and to other non-affiliated or affiliated parties as
permitted by law. In the event of a sale of all or part of our businesses,we may share customer information as part of the sale.We
do not sell mr share your information with outside marketers who may want Lo offer you their own products and services;
nor dmm/e share information vva receive about you from a consumer reporting agency.You dm not need to take any action
for this benefit.
Lincoln Financial Group is the marketing name for Lincoln mafionu|Corporation and its affiliates. Last updated:10/21
Lcm^2876003-121719
GLnO/14
. 10
~
T
Security 0@Information
We have an important responsibility to keep your ihformation safe.We use safeguards to protect your information from unauthorized
disclosure. Our employees are authorized to access your information only when they need it to perform their job responsibilities.
Employees who have access to your personal information are required to keep it confidential. Employees are required tocomplete
privacy training annually.
Your Rights Regarding Your Personal Information
This Privacy Notice describes how you can exercise your rights regarding your personal information. Lincoln complies with all
applicable laws and regulations regarding the provision of personal information.The rights provided UJ you inthis Privacy Notice will
be administered in accordance with your state's specific laws and regulations.
Access to personal information: You must submit a written request to receive a copy of your personal information.You may see
your personal information in pmronn, or you may ask us to send you a copy of your personal information by mail or electronically,
whichever you prefer.We will need to verify your identity before we process the request.Within 3Obusiness days of receiving your
request,we will,depending on the specific request you make, (1) inform you of the nature and substance of the recorded personal
information we have about you;(2) permit you to obtain a copy of your personal information;and (3)provide the identity(if recorded)
of persons to whom we disclosed your personal information within two years prior to the request(if this information is not recorded,
we will provide you with the names of those insurance institutions,agents,insurance support organizations or other persons to whom
such information is normally disclosed). If you request o copy of your information by mnoi|, we may charge you mfea for copying
and mailing costs.
Changes to personal information: If you believe that your personal information is inaccurate or incomplete, you may ask us to
correct,amend,or delete the information.Your request must be in writing and must include the reason you are requesting the change.
We will respond within 30 business days from the date we receive your request.
Ifvve make changes to your records as a result of your request,we will notify you in writing and we will send the updated information,
at your request,to any person who may have received your personal information within the past two years. We will also send the
updated information to any insurance support organization that gave us the information and any insurance support organization that
systematically received personal information from us within the prior 7years unless that support organization no |6ngar maintains
your personal information.
If we deny your request to correct, amend or delete your information,we will provide you with the reasons for the denial. You may
write to us and concisely describe what you believe our records should say and why you disagree with our denial of your request
to nonaot' ennend, or delete that information. We will file this communication from you with the disputed information, identify the
disputed information if it in disclosed, and provide notice ofthe disagreement to the persons and in the manner described in the
paragraph above.
Basis for adverse underwriting decision: You may ask in writing for the specific reasons for an adverse underwriting decision.
An adverse underwriting decision ia where xxe decline your application for insurance, offer to insure you at a higher than standard
rate, or terminate your coverage.
Your state may provide for additional privacy protections under applicable laws.We will protect your information in accordance with
these additional protections.
If you would like to act upon your rights regarding your personal information, please provide your full name, address and telephone
number and either email your inquiry to our Data Subject Access Request Teem at DSAR@|fq.nonn or mail to: Lincoln Financial
Group,Attn:Corporate Privacy Office,1301 South Harrison St,Fort Wayne,IN 46802.The DSAR@Ifg.com email address should only
be used for inquiries related to this Privacy Notice. For general account service requests or inquiries, please call 1-877-ASK-LINC.
*This information applies to the following Lincoln Financial Group companies:
First Penn-Pacific Life Insurance Company Lincoln Life 6i Annuity Company of New York
Lincoln Financial Diobibutony, Inc. Lincoln Life Assurance Company ofBoston
Lincoln Financial Group Trust Company Lincoln Retirement Services Company, LLC
Lincoln Investment Advisors Corporation Lincoln Variable Insurance Products Trust
The Lincoln National Life Insurance Company
*«This Notice iseffective 14 calendar days after\tis made available ou Lincoln's m/ebsite'vvvmw.LF[S.00rn/privacy.
Last updated:zmcz
Lcm'uurnnou'zuzrzs
GLom7z4
11
^
v
Lincoln Life&Annuity Company mf New York
Home Office: Synacu*e^NY13Z0Z
A|l Gnnup|n$urammequesdonsandomrrespondenoesendto:
r] Lincoln
Financial Group Insurance Sen�ceOffice
— "- 8DO1 Indian Hills Drive,Omaha,NG6U114
Phone:8OO'423-2765 Fax:877'573'6177
NEWYORK DISABILITY
'0E0&EF0FS AND PAID FAMILY LEAVE INSURANCE
EMPLOYER APPLICATION
Application is made to Lincoln Life & Annuity Company of New York (the Company), based upon the following statements, fora
group policy to provide insurance in accord with the Disability Benefits Law (DBL) and Paid Family Leave Benefits(PFQ Law of the
State nf New York(the Lavv).
1. Employer's Legal Name
DBA Name(if different)
Federal Tax|DNo.
l. Street Address
City,State,Zip
]. Billing Address(if different)
City,State,Zip
4. Any division,subsidiary or affiliated company tpbecovered:
(Attach e separate sheet for additional divisions,subsidiaries or affiliates)
Legal Name
Street Address
City,State,Zip
Federal Tax|D No.(if assigned)
S. Claims Information Contact Person: Phone
G. Private orPublic*Employer? Fl Private n Public*
*Public Employer means the state,any political subdivision of the state,a public authority or any other governmental agency or
instrumentality.
7. Nature ofBusiness:
nCorporahon Partnership F] Proprietorship Other(Specify)
8. The purpose of this application isto request,effective
issuance uf new coverage effective
�] include Paid Family Leave(PFL)coverage*
*Required for Private Employers and Voluntary for Public Employers
El Extension or 0 Deletion of existing coverage for the following Employee class(es):
Effective
�l Extension or E7 Deletion of existing coverage for the following Proprietu,/Portner(s):
Effective
g. The Policy is to cover all Employees eligible under the Law because of their employment with the Employer-,
|f adding wr excluding classes specifically for DBL coverage,indicate below(PFL only covers New York State employees)
�lAdditional Classes tobeIncluded:
E]classes to be Excluded:
mYDBL+4PP.18 Page
^
»
10. The is also to cover Proprietor/Partner(s) for the same coverage at additional premium charge (DBLcpwerage is at an
additional premium uherge):
|lYes F]No
The Employer certifies that each Proprietor/Partner is actually engaged full-tirne in the operation of the business,
11. Benefits(Choose One):
r-1 The Policy isto provide the benefits required by the Law.
El The Policy is to provide the benefits greater than required by the Law,listed below(Not applicable moPFL coverage):
Schedule of Insurance Employee's
Employee's Classification Rate of Weekly Benefit Contribution Plan of insurance
Weekiv Benefit is to begin on:
the_day of disability due to accident;
the_day of disability due to sickness;and is
to continue during disability but not to exceed
weeks for any one disability.
lZ. Total number of Employees tobe insured as required bythe Lae:
N1a!e Fema|e_________
Total Prop rietprs/PartnenToBeInsured:
Total Number of Any Other Employees:
13. FICA(This service is available for DBL coverage only.)
�] If this box is checked, Employer authorizes the Company to pay Employer's share of FICA taxes (FICA match) for D8L
benefits paid; to prepare, issue and file IRS form VV'2 for each employee; and to mail employees' copies directly to the
claimant. Requesting the DBL FICA match product may result in an increase in premium to cover additional services.
If this box is checked, Employer declines the Company FICA match service and agrees Employer will report and deposit
Employer's share of any FICA tax withheld from DBL benefits paid.
14. Form W-Z(This service is available for D8L coverage wm|y,) Please check one of the following year-end tax reporting options:
Employer will prepare and file its own Form W-3s.
Employer elects to have the Company print Form W-2s.
FRAUD WARNING/STATE DISCLOSURE(S):
PFL: A sole proprietor, a member of a limited liability company,a member of a limited liability partnership,or other self-employed
person who elects coverage under Article 9 of the WCL shall be subject to a waiting period of 2 years from the effective date of this
rider before PFL benefits are payab|e*. During the 2 year waiting period,premium contributions for PFL coverage shall be payable.
*EXCEPTION:Not applicable if the PFL rider is issued on or before 1/1/18 or within 26 weeks of when the employer first becomes a
sole proprietor,limited liability company,limited liability partnership,or other self-employed person.
A sole proprietor with employees, a member of a limited liability company with employees, a member of a limited liability
partnership with employees,or other self-employed person with employees must be covered under the same policy that covers the
policyholder's employees.
ACCIDENT&HEALTH INSURANCE FRAUD: Any person who knowingly and with intent to defraud any insurance company orother
person:
( files mn application for insurance or a statementmf claim containingmaterially false information;or
(2) conceals,for the purpose of misleading,information concerning any fact material thereto;
commits a fraudulent insurance act,which isocrime. Such person shall also be subject toa civil penalty not to exceed$5O00and
the stated value of the claim for each violation.
Writing Agent Signed by Applicant's Authorized Representative:
Or Broker's Signature
Typed ur Printed Name Signature
License Number: 3tate Typed or Printed Name
Genera|A§enl!s/3ubagent's
Signature Title
Typed or Printed Name Date
LicenseNumber: State_________
NYDBL'APP.18 Page