Quote Request Form for Private Paid Family Leave and Statutory Disability

Quote Request Form for Private Paid Family Leave and Statutory Disability

Landsman Insurance Services, LLC. NPN: 21500715 - 1-833-208-0034
Opt out of your state mandated Paid Family Leave or Statutory Disability Plan for a Private Plan

Who likes dealing with the state on anything? We can help save you and your employees thousands of dollars per year. Private insurance carriers offer a great claims experience and often pay much faster than the state plans. This helps to get $ in the pockets of your employees when they need it most. If you have employees in multiple states that requite statutory benefits, we can help unify the program with one carrier and claims experience for all of your employees, while allowing you to enjoy the convenience of one monthly remittance of premium to one entity.
Business Name
Description of services or SIC/NAICS Code
Business Web Address
How Many W-2 Employees does your business have?
Does your business currently have coverage in force?
What type of coverage does your business currently have? For Maine and Minnesota businesses please select "no coverage".
Please check all states where your business has W-2 employees
Corporate Headquarters Address

Street Address

Street Address Line 2

CityState / Province

Postal / Zip Code
Your Name:*

First NameLast Name
Your Title: Please Enter Here
Phone Number*
Please enter a valid phone number.
Email*
example@example.com
Please provide an Excel or .CSV file containing only the following information for all eligible employees: Gender, Date of Birth, Salary (annual) Full-time or Part-time Indicator, Occupation, State of their Primary Work Location. All data submitted within this form is encrypted.

WARNING: ANY PERSON WHO, KNOWINGLY OR WITH INTENT TO DEFRAUD OR TO FACILITATE A FRAUD AGAINST ANY INSURANCE COMPANY OR OTHER PERSON, SUBMITS AN APPLICATION OR FILES A CLAIM FOR INSURANCE CONTAINING FALSE, DECEPTIVE OR MISLEADING INFORMATION MAY BE GUILTY OF INSURANCE FRAUD.
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Quote Request Form for Private Paid Family Leave and Statutory Disability

Opt out of your state mandated Paid Family Leave or Statutory Disability Plan for a Private Plan