Groups of 50 or More Lives

To Request a Quote please answer all questions that follow:

Broker Submitting Quote Request:
First Name:		City
Last Name:		State
Company:		Zip
Street Address 1:		Phone#:
Street Address 2:		Fax#:
		E-Mail:

Employer Name:		Street:
City, State, Zip:

Unemployment Insurance Number		(or Unassigned)
S.S. or Fed Tax ID Number
Nature of Business:
Form of Organization:
No. of Employees to be insured:	Male:	Female:

Desired Effective Date of Coverage:
Previous Carrier:
Termination Date:
Name of Workers Comp Carrier:
Additional Employers to be included as Covered Employers:
Are you the broker on this line now?

In addition to completing the above application please FAX to us:

Our Fax Number is: 631 265-7054

Do you wish your proposal sent to you by:

Mail Fax E-Mail

Want to know more about DBL Insurance,
please feel free to email us at: DBL@victorson.com