| Form Id |
Form Name |
Description |
Word |
PDF |
| TDB QQ1 |
Quick Quote Request - New Jersey TDB |
To request a NJ TDB quote for employer groups with 25 or more employees. |
N/A |
 |
| TDB-AP1 |
DBL NJ TDB Application |
To apply for NJ Temporary Disability coverage with National Benefit Life, must be submitted along with DP-1. |
 |
|
| DP-1 |
Application for Approval or Modification of Insured Private Plan |
Used to apply for new private plan or change to existing private plan. |
|
|
| DP-1A |
Statement of Exclusions Under Proposed Private Plan |
Used when some employees are excluded from the private plan. |
|
|
| DP-1(Instructions) |
Instructions for completing the DP-1 |
Guide to assist in completing the NJ TDB Form DP-1. |
N/A |
|
| TDB-C |
Employee Consent (individual) |
Individual employee consent form. |
N/A |
|
| TDB-CF |
Employee Consent (group) |
Employee consent form in list format. |
N/A |
|
| Form Id |
Form Name |
Description |
Word |
PDF |
| WDS-1 |
NJ-TDB Claim Form |
Claim form used to file a NJ TDB claim when an employee becomes disabled while employed or within 14 days after termination. Must be filed with NBL within 30 days of disability. |
N/A |
|
| NJ-Part-C |
Notice to Employer |
Sent to employer requesting information on a TDB claimant. Form must be completed and returned to NBL. |
N/A |
|
| 14A |
Request for Updated Medical Information |
Supplemental Medical Form - to be completed by claimant and their attending physician. |
N/A |
|