DATE
DEAR APPLICANT:
a.
b.
c.
d.
NYS FORM NF-1A (Rev 6/2013)
Page 1 of 2
a $2,000 death benefit, payable to the estate of a covered person, in addition to the $50,000 coverage for
economic loss described above.
Additional benefits may be owed to you if the above policy has been endorsed to include Optional Basic Economic Loss
coverage and/or Additional Personal Injury Protection coverage.
In determining the benefits payable to you under the No-Fault Law, amounts recovered or recoverable on account of the
accident from Workers' Compensation, New York State Disability, and certain wage continuation plans will reduce your No-
Fault benefits. Therefore, if you are entitled to any of these benefits you should make your claim for them promptly.
If you are a named insured or relative under a Mandatory Personal Injury Protection policy which includes OBEL coverage,
you may be entitled to an additional $25,000 of Basic Economic Loss coverage. You should make your claim to that motor
vehicle insurer promptly, but in no event later than 90 days after your $50,000 of Basic Economic Loss coverage under this
policy is exhausted.
NOTE: The No-Fault Law provides that if you are injured on a bus or a school bus in New York State, No-Fault benefits must
be paid by your auto insurer or if you have no auto, the auto insurer of a relative with whom you reside. The law further
provides that you should only file a No-Fault claim with the insurer of the bus or school bus if there is no such auto policy in
your household. If the above rule does not apply, you may file a No-Fault claim with the insurer of the bus or school bus if
you are the operator, owner or employee of the owner of the bus company.
NAME AND ADDRESS OF APPLICANT
COMPLETE THE ATTACHED DB-450 FORM
IMMEDIATELY IF YOU ARE ENTITLED TO NEW
YORK STATE DISABILITY BENEFITS AND MAIL OR
GIVE IT TO YOUR EMPLOYER. TO FIND OUT IF
YOU ARE ELIGIBLE, TELEPHONE THE NEW YORK
STATE DISABILITY BENEFITS BUREAU AT (800)
353-
3092
This will acknowledge receipt of notice that you may have sustained injuries in the above captioned accident. The New York
No-Fault Law provides for the payment of benefits to victims of motor vehicle accidents to reimburse them for their basic
economic loss. Briefly summarized, basic economic loss consists of up to $50,000 per person in benefits for the following:
all necessary doctor and hospital bills and other health service expenses, payable in accordance with fee
schedules established or adopted by the New York State Department of Financial Services;
80% of lost earnings up to a maximum monthly payment of $2,000 for up to three years following the date of the
accident;
up to $25 per day for a period of one year from the date of the accident for other reasonable and necessary
expenses the injured person may have incurred because of an injury resulting from the accident, such as the cost
of hiring a housekeeper or necessary transportation expenses to and from a health service provider; and
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
COVER LETTER
NAME, ADDRESS AND PHONE NUMBER OF
INSURER, SELF-INSURER OR REPRESENTATIVE*
NAME, ADDRESS AND PHONE NUMBER OF CLAIM
REPRESENTATIVE*
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
Very truly yours,
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-1A (Rev 6/2013)
Page 2 of 2
PLEASE ANSWER ALL QUESTIONS ON THE APPLICATION FORM AND SIGN BOTH
AUTHORIZATIONS SO THAT WE MAY GIVE PROMPT ATTENTION TO YOUR CLAIM
COVER LETTER -- PAGE TWO
To enable us to determine if you are entitled to any No-Fault benefits, please complete and immediately return the enclosed
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS (NYS FORM NF-2) along with copies of any bills you have
received to date. This application must be sent to us within 30 days of the accident date if your original notice to us was not in
writing.
You are entitled to receive health service benefits without any time limit if it is possible to determine during the first
year after the accident that further health services may be required after the first year. As you receive additional
medical bills or any other bills you believe to be covered, send them to us immediately. In order to be considered
for payment, all bills for health care services must be submitted within 45 days of treatment. If it is not possible for
you or your health care provider to submit these bills within that time period, submit a written explanation of the
reason for the delay. Claims for lost earnings and other reasonable and necessary expenses must be submitted
within 90 days. We will reimburse you as soon as we are able to verify that they are covered expenses under No-
Fault. Please identify all communications with us with the claim number shown above. Should you have any
questions concerning your claim, we will be most happy to assist you. Please feel free to call the claim
representative at the phone number provided at the top of page one.
PLEASE NOTE THAT THE TIME ALLOWED FOR PROVIDING NOTICE AND PROOF OF CLAIM TO YOUR INSURER
HAS BEEN REDUCED. FAILURE TO RETURN A COMPLETED APPLICATION FOR MOTOR VEHICLE NO-FAULT
BENEFITS FORM (NF-2) TO YOUR INSURER TIMELY CAN RESULT IN LOSS OF ALL BENEFITS. FAILURE TO SUBMIT
BILLS FOR HEALTH CARE SERVICES WITHIN 45 DAYS OF TREATMENT OR MAKE CLAIM FOR LOST EARNINGS OR
OTHER REASONABLE AND NECESSARY EXPENSES WITHIN 90 DAYS OF OCCURRENCE CAN RESULT IN THOSE
BENEFITS BEING DENIED. If your insurer denies coverage for failure to make a timely submission you can provide
them with a written reply stating why you could not reasonably meet the time frames and your insurer must
consider it.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM
FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR
CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH
ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF
ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES
OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND
SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE
VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
IMPORTANT REMINDERS
DATE
DEAR APPLICANT:
a.
b.
c.
d.
NYS FORM NF-1B (Rev 6/2013)
Page 1 of 2
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
COVER LETTER
NAME, ADDRESS AND PHONE NUMBER OF
INSURER, SELF-INSURER OR REPRESENTATIVE*
NAME, ADDRESS AND PHONE NUMBER OF CLAIM
REPRESENTATIVE*
NAME AND ADDRESS OF APPLICANT
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT
COMPLETE THE ATTACHED DB-450 FORM
IMMEDIATELY IF YOU ARE ENTITLED TO NEW
YORK STATE DISABILITY BENEFITS AND MAIL OR
GIVE IT TO YOUR EMPLOYER. TO FIND OUT IF
YOU ARE ELIGIBLE, TELEPHONE THE NEW YORK
STATE DISABILITY BENEFITS BUREAU AT (800)
353-
3092
CLAIM NUMBER
This will acknowledge receipt of notice that you may have sustained injuries in the above captioned accident. The New York
No-Fault Law provides for the payment of benefits to victims of motor vehicle accidents to reimburse them for their basic
economic loss. Briefly summarized, basic economic loss consists of up to $50,000 per person in benefits for the following:
all necessary doctor and hospital bills and other health service expenses, payable in accordance with fee
schedules established or adopted by the New York State Department of Financial Services;
80% of lost earnings up to a maximum monthly payment of $2,000 for up to three years following the date of the
accident;
up to $25 per day for a period of one year from the date of the accident for other reasonable and necessary
expenses the injured person may have incurred because of an injury resulting from the accident, such as the cost
of hiring a housekeeper or necessary transportation expenses to and from a health service provider; and
a $2,000 death benefit, payable to the estate of a covered person, in addition to the $50,000 coverage for
economic loss described above.
Additional benefits may be owed to you if the above policy has been endorsed to include Optional Basic Economic Loss
coverage and/or Additional Personal Injury Protection coverage.
In determining the benefits payable to you under the No-Fault Law, amounts recovered or recoverable on account of the
accident from Workers' Compensation, New York State Disability, and certain wage continuation plans will reduce your No-
Fault benefits. Therefore, if you are entitled to any of these benefits you should make your claim for them promptly.
If you are a named insured or relative under a Mandatory Personal Injury Protection policy which includes OBEL coverage,
you may be entitled to an additional $25,000 of Basic Economic Loss coverage. You should make your claim to that motor
vehicle insurer promptly, but in no event later than 90 days after your $50,000 of Basic Economic Loss coverage under this
policy is exhausted.
NOTE: The No-Fault Law provides that if you are injured on a bus or a school bus in New York State, No-Fault benefits must
be paid by your auto insurer or if you have no auto, the auto insurer of a relative with whom you reside. The law further
provides that you should only file a No-Fault claim with the insurer of the bus or school bus if there is no such auto policy in
your household. The above rule does not apply and you may file a No-Fault claim with the insurer of the bus or school bus if
you are the operator, owner or employee of the owner of the bus company.
Very truly yours,
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-1B (Rev 6/2013)
Page 2 of 2
You are entitled to receive health service benefits without any time limit if it is possible to determine during the first
year after the accident that further health services may be required after the first year. As you receive additional
medical bills or any other bills you believe to be covered, send them to us immediately. In order to be considered
for payment, all bills for health care services must be submitted within 180 days of treatment. If it is not possible
for you or your health care provider to submit these bills within that time period, submit a written explanation of the
reason for the delay. Claims for other reasonable and necessary expenses must be submitted within 90 days.
We will reimburse you as soon as we are able to verify that they are covered expenses under No-Fault. Please
identify all communications with us with the claim number shown above. Should you have any questions
concerning your claim, we will be most happy to assist you. Please feel free to call the claim representative at the
phone number provided at the top of page one.
PLEASE ANSWER ALL QUESTIONS ON THE APPLICATION FORM AND SIGN BOTH
AUTHORIZATIONS SO THAT WE MAY GIVE PROMPT ATTENTION TO YOUR CLAIM
To enable us to determine if you are entitled to any No-Fault benefits, please complete and immediately return the enclosed
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS (NYS FORM NF-2) along with copies of any bills you have
received to date. This application must be sent to us within 90 days of the accident date if your original notice to us was not in
writing.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM
FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR
CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH
ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF
ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES
OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND
SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE
VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
IMPORTANT REMINDERS
COVER LETTER -- PAGE TWO
DATE
IMPORTANT:
1. YOUR NAME 2. PHONE NOS. HOME BUSINESS
3. YOUR ADDRESS 4. DATE OF BIRTH 5. SOCIAL SECURITY NO.
(NO., STREET, CITY OR TOWN AND ZIP CODE)
6. DATE AND TIME OF ACCIDENT 7. PLACE OF ACCIDENT (STREET), CITY OR TOWN AND STATE
A.M.
P.M.
8. BRIEF DESCRIPTION OF ACCIDENT
9. DESCRIBE YOUR INJURY
10. IDENTITY OF VEHICLE YOU OCCUPIED OR OPERATED AT THE TIME OF THE ACCIDENT:
THIS VEHICLE WAS: A BUS OR SCHOOL BUS, A TRUCK, AN AUTOMOBILE,
OR A MOTORCYCLE
YES NO
11. WERE YOU THE DRIVER OF THE MOTOR VEHICLE?
WERE YOU A PASSENGER IN THE MOTOR VEHICLE?
WERE YOU A PEDESTRIAN?
WERE YOU A MEMBER OF OUR POLICYHOLDER’S HOUSEHOLD?
DO YOU OR A RELATIVE WITH WHOM YOU RESIDE OWN A MOTOR VEHICLE?
NYS FORM NF-2 (Rev 1/2004)
Page 1 of 3
CONTINUATION ON NEXT PAGE
NAME AND ADDRESS OF APPLICANT*
OWNER'S NAME
MAKE YEAR
TO ENABLE US TO DETERMINE IF YOUR ARE ENTITLED TO BENEFITS UNDER THE NEW YORK NO-FAULT LAW,
PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY.
1. TO BE ELIGIBLE FOR BENEFITS YOU MUST COMPLETE AND SIGN THIS APPLICATION.
2. YOU MUST SIGN ANY ATTACHED AUTHORIZATION(S).
3. RETURN PROMPTLY WITH COPIES OF ANY BILLS YOU HAVE RECEIVED TO DATE.
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS
NAME AND ADDRESS OF INSURER *
NAME, ADDRESS, AND PHONE NUMBER OF INSURER’S
CLAIMS REPRESENTATIVE*
12. WERE YOU TREATED BY A DOCTOR(S) OR OTHER PERSON(S) FURNISHING HEALTH SERVICES?
YES NO
IF YES, NAME AND ADDRESS OF SUCH DOCTOR(S) OR PERSON(S):
13. IF YOUR WERE TREATED AT A HOSPITAL(S), WERE YOU AN
OUT-PATIENT? IN-PATIENT?
DATE OF ADMISSION:
HOSPITAL'S NAME AND ADDRESS:
14. AMOUNT OF HEALTH 15. WILL YOU HAVE MORE HEALTH 16. AT THE TIME OF YOUR ACCIDENT WERE
BILLS TO DATE: TREATMENT(S)? YOU IN THE COURSE OF YOUR
YES NO EMPLOYMENT?
$ YES NO
17. DID YOU LOSE TIME DATE ABSENCE FROM HAVE YOU RETURNED TO
FROM WORK? WORK BEGAN: WORK?
YES NO YES NO
IF YES, DATE RETURNED TO WORK: AMOUNT OF TIME LOST FROM WORK:
18. WHAT ARE YOUR GROSS AVERAGE NUMBER OF DAYS YOU WORK NUMBER OF HOURS YOU WORK
WEEKLY EARNINGS? PER WEEK: PER DAY:
19. WERE YOU RECEIVING UNEMPLOYMENT BENEFITS AT THE TIME OF THE ACCIDENT?
YES NO
20. LIST NAMES AND ADDRESS OF YOUR EMPLOYER AND OTHER EMPLOYERS FOR ONE YEAR PRIOR TO
ACCIDENT DATE AND GIVE OCCUPATION AND DATES OF EMPLOYMENT:
EMPLOYER AND ADDRESS OCCUPATION FROM TO
EMPLOYER AND ADDRESS OCCUPATION FROM TO
EMPLOYER AND ADDRESS OCCUPATION FROM TO
21. AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES?
YES NO
IF YES, ATTACH EXPLANATION AND AMOUNTS OF SUCH EXPENSES.
22. DUE TO THIS ACCIDENT HAVE YOU RECEIVED OR ARE YOU ELIGIBLE FOR PAYMENTS
UNDER ANY OF THE FOLLOWING:
YES NO
NEW YORK STATE DISABILITY?
WORKERS' COMPENSATION?
NYS FORM NF-2 (Rev 1/2004)
Page 2 of 3
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS - - PAGE TWO
CONTINUATION ON NEXT PAGE
THE APPLICANT AUTHORIZES THE INSURER TO SUBMIT ANY AND ALL OF THESE FORMS TO ANOTHER PARTY
OR INSURER IF SUCH IS NECESSARY TO PERFECT ITS RIGHTS OF RECOVERY PROVIDED FOR UNDER THE
NO-FAULT LAW.
(IF THE APPLICANT IS A MINOR, PARENT OR GUARDIAN SHALL SIGN AND INDICATE CAPACITY AND RELATIONSHIP).
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-2 (Rev 1/2004)
Page 3 of 3
THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY
HAVE REGARDING MY CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY
OBTAINED, X-RAYS AND PHYSICAL FINDINGS, DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE
THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE
REPARATIONS ACT
(
NO-FAULT LAW
)
.
NAME (PRINT OR TYPE)
SIGNATURE DATE
SIGNATURE DATE
DO NOT DETACH
AUTHORIZATION FOR RELEASE OF HEALTH SERVICE OR TREATMENT INFORMATION
AUTHORIZATION FOR RELEASE OF WORK AND OTHER LOSS INFORMATION
THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY
HAVE REGARDING MY WAGES, SALARY OR OTHER LOSS WHILE EMPLOYED BY YOU. YOUR ARE AUTHORIZED TO
PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE
INSURANCE REPARATIONS ACT (NO-FAULT LAW).
NAME (PRINT OR TYPE) SOCIAL SECURITY NO.
SIGNATURE DATE
DO NOT DETACH
THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE
APPLICANT AS TRUE UNDER THE PENALTIES OF PERJURY
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY
COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION,
OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL
THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY
MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE
REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW
ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY,
COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL
PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE
OR STATED CLAIM FOR EACH VIOLATION.
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS - - PAGE THREE
DATE
IF YOU HAVE PREVIOUSLY SUBMITTED AN EARLIER REPORT ON THIS ACCIDENT, YOU NEED ONLY NOTE ANY
CHANGES FROM THE INFORMATION PREVIOUSLY FURNISHED AND ADDITIONAL CHARGES.
1. PATIENT'S NAME AND ADDRESS
2. DATE OF BIRTH 3. SEX 4. OCCUPATION (IF KNOWN)
5. DIAGNOSIS AND CONCURRENT CONDITIONS
6. WHEN DID SYMPTOMS FIRST APPEAR? 7. WHEN DID PATIENT FIRST CONSULT YOU FOR THIS
DATE: CONDITION? DATE:
8. HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION?
YES NO IF YES, state when and describe:
9. IS CONDITION SOLELY A RESULT OF THIS AUTOMOBILE ACCIDENT?
YES NO IF "NO", explain:
10. IS CONDITION DUE TO INJURY ARISING OUT OF PATIENT’S EMPLOYMENT?
YES NO
11. WILL INJURY RESULT IN SIGNIFICANT DISFIGUREMENT OR PERMANENT DISABILITY?
YES NO NOT DETERMINABLE AT THIS TIME
IF "YES", describe:
12. PATIENT WAS DISABLED (UNABLE TO WORK) 13. IF STILL DISABLED THE PATIENT SHOULD BE
ABLE TO RETURN TO WORK ON:
FROM: THROUGH:
NYS FORM NF-3 (Rev 1/2004)
Page 1 of 3
PROVIDER'S NAME AND ADDRESS*
KINDLY COMPLETE AND SUBMIT THIS FORM AS SOON AS POSSIBLE. PLEASE NOTE, THIS COMPLETED
FORM MUST BE SUBMITTED TO THE INSURER AS SOON AS REASONABLY POSSIBLE BUT NO LATER
THAN 45 DAYS OR 180 DAYS AFTER THE TREATMENT DATE, DEPENDING UPON THE POLICY
ENDORSEMENT IN EFFECT AT THE TIME OF THE ACCIDENT. IF YOU ARE UNSURE OF THE APPLICABLE
TIME REQUIREMENT, KINDLY CONTACT THE CLAIMS REPRESENTATIVE TO DETERMINE WHICH
DEADLINE IS APPLICABLE TO THIS CLAIM
.
(DATE)
CONTINUE ON PAGE 2
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
(This form is not
for verification of hospital treatment )
NAME AND ADDRESS OF INSURER OR SELF-
INSURER*
NAME, ADDRESS, AND PHONE NUMBER OF
INSURER’S CLAIMS REPRESENTATIVE*
14. WILL THE PATIENT REQUIRE REHABILITATION AND/OR OCCUPATIONAL THERAPY AS A RESULT OF THE
INJURIES SUSTAINED IN THIS ACCIDENT?
YES NO IF YES, describe your recommendation below:
15. REPORT OF SERVICES RENDERED -- ATTACH ADDITIONAL SHEETS IF NECESSARY
DATE OF
SERVICE
TOTAL CHARGES TO DATE$
16. IF TREATING PROVIDER IS DIFFERENT THAN BILLING PROVIDER COMPLETE THE FOLLOWING:
EMPLOYEE OTHER (SPECIFY)
17. IF THE PROVIDER OF SERVICE IS A PROFESSIONAL SERVICE CORPORATION OR DOING BUSINESS
UNDER AN ASSUMED NAME (DBA), LIST THE OWNER AND PROFESSIONAL LICENSING CREDENTIALS OF
ALL OWNERS (Provide an additional attachment if necessary).
18. IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION? YES NO
19. ESTIMATED DURATION OF FUTURE TREATMENT
20.
(IF YOU HAVE CHOSEN TO AUTHORIZE THE DIRECT PAYMENT OF BENEFITS BY CHECKING THIS OPTION, YOU MAY NOT
ALSO ENTER INTO AN ASSIGNMENT OF BENEFITS CONTAINED IN #21)
AUTHORIZATION TO PAY BENEFITS:
PRINT NAME SIGNED
DATE
NYS FORM NF-3 (Rev 1/2004)
Page 2 of 3
PATIENT PATIENT
CONTINUE ON PAGE 3
INDEPENDENT
CONTRACTOR
PATIENT: Your health provider may agree to accept payment for health services performed directly from your insurer (Authorization to
Pay Benefits) so that you are not required to make payment to the health provider at the time of service. Such agreement is optional on
the part of the health provider and must be signed by both patient and health provider. You may use the optional authorization language
provided below, by checking off the designated spot in item 20 of this form.
I AUTHORIZE PAYMENT OF HEALTH BENEFITS TO THE UNDERSIGNED HEALTH CARE PROVIDER OR SUPPLIER OF SERVICES
DESCRIBED BELOW. I RETAIN ALL RIGHTS, PRIVILEGES AND REMEDIES TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE
NO-FAULT PROVISION) OF THE INSURANCE LAW.
INCLUDING ZIP CODE OR HEALTH SERVICE RENDERED TREATMENT CODE
TREATING PROVIDER'S
TITLE
LICENSE OR BUSINESS RELATIONSHIP
NAME CERTIFICATION NO. CHECK APPLICABLE BOX
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
PAGE 2
PLACE OF SERVICE DESCRIPTION OF TREATMENT FEE SCHEDULE CHARGES
21.
(IF YOU HAVE CHOSEN TO ASSIGN YOUR BENEFITS TO THE HEALTH PROVIDER BY CHECKING THIS OPTION, YOU MAY NOT
ALSO ENTER INTO AN AUTHORIZATION TO PAY BENEFITS CONTAINED IN ITEM #20 ABOVE)
ASSIGNMENT OF NO-FAULT BENEFITS
:
PRINT NAME SIGNED
DATE
PRINT NAME SIGNED
DATE
HAS AN ORIGINAL AUTHORIZATION OR ASSIGNMENT PREVIOUSLY
BEEN EXECUTED? YES NO
IS THE ORIGINAL SIGNATURE OF THE PARTIES ON FILE? YES NO
DATE
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-3 (Rev 1/2004)
Page 3 of 3
IF NONE, SPECIALTY
PROVIDER OF HEALTH CARE SERVICE (Assignee) PROVIDER OF HEALTH CARE SERVICE
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY
COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR
CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO,
AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR
KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE
THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT
AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT
INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED
FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH
VIOLATION.
PROVIDER'S SIGNATURE IRS/TIN IDENTIFICATION NO. WCB RATING CODE
PAGE 3
PATIENT: Your health provider may agree to have you assign your right to No-Fault benefits from your insurer directly to your health
provider (Assignment of Benefits). If you and your health provider agree to an assignment of benefits, you must both sign the
agreement contained in # 21 or the prescribed NF-AOB form or its equivalent. The language contained in the assignment of benefits is
mandatory and may not be altered or avoided by any other language added to this agreement or other written agreement.
I HEREBY ASSIGN TO THE HEALTH CARE PROVIDER INDICATED BELOW ALL RIGHTS, PRIVILEGES AND REMEDIES TO
PAYMENT FOR HEALTH CARE SERVICES PROVIDED BY THE ASSIGNEE TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE
NO-FAULT STATUTE) OF THE INSURANCE LAW. THE ASSIGNEE HEREBY CERTIFIES THAT THEY HAVE NOT RECEIVED ANY
PAYMENT FROM OR ON BEHALF OF THE ASSIGNOR AND SHALL NOT PURSUE PAYMENT DIRECTLY FROM THE ASSIGNOR
FOR SERVICES PROVIDED BY SAID ASSIGNEE FOR INJURIES SUSTAINED DUE TO THE MOTOR VEHICLE ACCIDENT,
NOTWITHSTANDING ANY OTHER AGREEMENT TO THE CONTRARY. THIS AGREEMENT MAY BE REVOKED BY THE ASSIGNEE
WHEN BENEFITS ARE NOT PAYABLE BASED UPON THE ASSIGNOR'S LACK OF COVERAGE AND/OR VIOLATION OF A POLICY
CONDITION DUE TO THE ACTIONS OR CONDUCT OF THE ASSIGNOR
PATIENT (Assignor) PATIENT
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
DATE
1. PATIENT'S NAME 2.DATE OF BIRTH
3. PATIENT'S ADDRESS
4. DATE ADMITTED
A.M. A.M.
P.M.
P.M.
8.a ADMITTING DIAGNOSIS:
8.b DISCHARGE DIAGNOSIS:
9. IS CONDITION DUE TO INJURY ARISING OUT OF PATIENT'S EMPLOYMENT?
YES NO
10. OPERATIONS OR PROCEDURES PERFORMED (NATURE AND DATES):
11. WAS TREATMENT RENDERED SOLELY AS A RESULT OF THE ABOVE ACCIDENT?
YES NO
IF NO, PLEASE EXPLAIN.
12. IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION?
YES NO
IF YES, PLEASE EXPLAIN AND INDICATE DURATION.
13. ATTACH REPORT OF SERVICES RENDERED AND ATTACH ITEMIZED BILL
HOSPITAL CHARGES MUST BE COMPUTED IN ACCORDANCE WITH RATES PERMITTED BY SECTION 5108 OF
THE NEW YORK INSURANCE LAW AND INSURANCE REGULATION NO. 83.
NYS FORM NF-4 (Rev 6/2013)
Page 1 of 2
DATE OF ACCIDENT CLAIM NUMBERPOLICY NUMBERPOLICYHOLDER
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
VERIFICATION OF HOSPITAL TREATMENT
NAME AND ADDRESS OF INSURER OR SELF-
INSURER*
NAME, ADDRESS, AND PHONE NUMBER OF
INSURER’S CLAIMS REPRESENTATIVE*
NAME AND ADDRESS OF HOSPITAL*
7. TIME DISCHARGED6. DATE DISCHARGED5. TIME ADMITTED
KINDLY COMPLETE AND SUBMIT THIS FORM AS SOON AS POSSIBLE.
PLEASE NOTE, THIS COMPLETED
FORM MUST BE SUBMITTED TO THE INSURER AS SOON AS REASONABLY POSSIBLE BUT NO LATER
THAN 45 DAYS OR 180 DAYS AFTER TREATMENT DATE, DEPENDING UPON THE POLICY
ENDORSEMENT IN EFFECT AT THE TIME OF THE ACCIDENT. IF YOU ARE UNSURE OF THE
APPLICABLE TIME REQUIREMENT, KINDLY CONTACT THE CLAIM REPRESENTATIVE TO DETERMINE
WHICH DEADLINE IS APPLICABLE TO THIS CLAIM.
14.
(IF YOU HAVE CHOSEN TO AUTHORIZE THE DIRECT PAYMENT OF BENEFITS BY CHECKING THIS OPTION,
YOU
MAY NOT ALSO ENTER INTO AN ASSIGNMENT OF BENEFITS CONTAINED IN #15)
AUTHORIZATION TO PAY BENEFITS:
PRINT NAME SIGNED
DATE
15.
(IF YOU HAVE CHOSEN TO ASSIGN YOUR BENEFITS TO THE HEALTH PROVIDER BY CHECKING THIS OPTION,
YOU MAY NOT ALSO ENTER INTO AN AUTHORIZATION TO PAY BENEFITS CONTAINED IN ITEM #14 ABOVE).
ASSIGNMENT OF NO-FAULT BENEFITS:
PRINT NAME SIGNED
DATE
PRINT NAME SIGNED
DATE
HAS AN ORIGINAL AUTHORIZATION OR ASSIGNMENT PREVIOUSLY
BEEN EXECUTED? YES NO
IS THE ORIGINAL SIGNATURE OF THE PARTIES ON FILE? YES NO
TAKEN BY:
(TITLE) (DATE)
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-4 (Rev 6/2013)
Page 2 of 2
(SIGNATURE) (PHONE NO. & EXT.)
(PATIENT)
PATIENT: Your health provider may agree to have you assign your right to No-Fault benefits from your insurer directly to your health
provider (Assignment of Benefits). If you and your health provider agree to an assignment of benefits, you must both sign the
agreement contained in # 15 or the prescribed NF-AOB form or its equivalent. The language contained in the assignment of benefits is
mandatory and may not be altered or avoided by any other language added to this agreement or other written agreement.
I HEREBY ASSIGN TO THE HEALTH CARE PROVIDER INDICATED ABOVE ALL RIGHTS, PRIVILEGES AND REMEDIES TO
PAYMENT FOR HEALTH CARE SERVICES PROVIDED BY THE ASSIGNEE TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE
NO-FAULT STATUTE) OF THE INSURANCE LAW. THE ASSIGNEE HEREBY CERTIFIES THAT THEY HAVE NOT RECEIVED ANY
PAYMENT FROM OR ON BEHALF OF THE ASSIGNOR AND SHALL NOT PURSUE PAYMENT DIRECTLY FROM THE ASSIGNOR
FOR SERVICES PROVIDED BY SAID ASSIGNEE FOR INJURIES SUSTAINED DUE TO THE MOTOR VEHICLE ACCIDENT,
NOTWITHSTANDING ANY OTHER AGREEMENT TO THE CONTRARY. THIS AGREEMENT MAY BE REVOKED BY THE
ASSIGNEE WHEN BENEFITS ARE NOT PAYABLE BASED UPON THE ASSIGNOR'S LACK OF COVERAGE AND/OR VIOLATION
OF A POLICY CONDITION DUE TO THE ACTIONS OR CONDUCT OF THE ASSIGNOR.
PATIENT (Assignor)
HOSPITAL REPRESENTATIVE (Assignee) HOSPITAL REPRESENTATIVE (Assignee)
PATIENT (Assignor)
VERIFICATION OF HOSPITAL TREATMENT -- PAGE TWO
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY
COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR
CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO,
AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR
KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE
THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT
AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT
INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED
FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH
VIOLATION.
PATIENT: Your health provider may agree to accept payment for health services performed directly from your insurer (Authorization to
Pay Benefits) so that you are not required to make payment to the health provider at the time of service. Such agreement is optional on
the part of the health provider and must be signed by both patient and health provider. You may use the optional authorization language
provided below, by checking off the designated spot in item 14 of this form.
I AUTHORIZE PAYMENT OF HEALTH BENEFITS TO THE UNDERSIGNED HEALTH CARE PROVIDER OR SUPPLIER OF
SERVICES DESCRIBED BELOW. I RETAIN ALL RIGHTS, PRIVILEGES AND REMEDIES TO WHICH I AM ENTITLED UNDER
ARTICLE 51 (THE NO-FAULT PROVISION) OF THE INSURANCE LAW.
(PATIENT)
1. INSURANCE COMPANY 2. ADDRESS OF INSURANCE COMPANY
3. PATIENT'S NAME AND ADDRESS 4. DATE OF BIRTH 5. PHONE NUMBER
6. AUTOMOBILE POLICY NUMBER 7. NAME AND ADDRESS OF POLICYHOLDER
8. ACCIDENT DATE 9. ADMISSION DATE 10. DISCHARGE DATE
11. PLACE OF ACCIDENT
12. DESCRIPTION OF ACCIDENT
13. IDENTITY OF VEHICLE OCCUPIED OR OPERATED AT THE TIME OF THE ACCIDENT:
THIS VEHICLE WAS: A BUS OR SCHOOL BUS, A TRUCK, AN AUTOMOBILE,
OR A MOTORCYCLE
YES NO
14. WAS PATIENT THE DRIVER OF THE MOTOR VEHICLE?
WAS PATIENT A PASSENGER IN THE MOTOR VEHICLE?
WAS PATIENT A PEDESTRIAN?
WAS PATIENT A MEMBER OF THE POLICYHOLDERS HOUSEHOLD?
15. ADMITTING DIAGNOSIS:
16. DISCHARGE DIAGNOSIS:
17. IS CONDITION DUE TO INJURY ARISING OUT OF PATIENT'S EMPLOYMENT?
YES NO
18. WAS TREATMENT RENDERED SOLELY AS A RESULT OF INJURIES ARISING OUT OF THE ABOVE ACCIDENT?
YES NO
IF NO, PLEASE EXPLAIN.
19. OPERATIONS OR PROCEDURES PERFORMED (NATURE AND DATES):
20. ATTACH REPORT OF SERVICES RENDERED HOSPITAL CHARGES MUST BE COMPUTED IN ACCORDANCE
AND ITEMIZED BILL WITH RATES PERMITTED BY SECTION 5108 OF THE NEW
YORK INSURANCE LAW AND INSURANCE
REGULATION NO. 83.
TAKEN BY:
DATE TAKEN FROM RECORDS:
NYS FORM NF-5 (Rev 6/2013)
Page 1 of 2
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
HOSPITAL FACILITY FORM
OWNER'S NAME MAKE YEAR
KINDLY COMPLETE AND SUBMIT THIS FORM AS SOON AS POSSIBLE.
PLEASE NOTE, THIS COMPLETED
FORM MUST BE SUBMITTED TO THE INSURER AS SOON AS REASONABLY POSSIBLE BUT NO LATER
THAN 45 DAYS OR 180 DAYS AFTER TREATMENT DATE, DEPENDING UPON THE POLICY
ENDORSEMENT IN EFFECT AT THE TIME OF THE ACCIDENT. IF YOU ARE UNSURE OF THE
APPLICABLE TIME REQUIREMENT, KINDLY CONTACT THE CLAIM REPRESENTATIVE TO DETERMINE
WHICH DEADLINE IS APPLICABLE TO THIS CLAIM.
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN
APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL
INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF
MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH
SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH
ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO
A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A
FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE
THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
PRINT NAME TITLE & PHONE NO.
SIGNATURE DATE
A.
(IF YOU HAVE CHOSEN TO AUTHORIZE THE DIRECT PAYMENT OF BENEFITS BY CHECKING THIS OPTION,
YOU MAY NOT ALSO ENTER INTO AN ASSIGNMENT OF BENEFITS CONTAINED IN ITEM B).
AUTHORIZATION TO PAY BENEFITS:
SIGNED SIGNED
B.
(IF YOU HAVE CHOSEN TO ASSIGN YOUR BENEFITS TO THE HEALTH PROVIDER BY CHECKING THIS OPTION,
YOU MAY NOT ALSO ENTER INTO AN AUTHORIZATION TO PAY BENEFITS CONTAINED IN ITEM #A ABOVE).
ASSIGNMENT OF NO-FAULT BENEFITS:
SIGNED
SIGNED
HAS AN ORIGINAL AUTHORIZATION OR ASSIGNMENT PREVIOUSLY
BEEN EXECUTED? YES NO
IS THE ORIGINAL SIGNATURE OF THE PARTIES ON FILE? YES NO
NYS FORM NF-5 (Rev 6/2013)
THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE
REGARDING MY CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED,
X-RAY AND PHYSICAL FINDINGS, DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN
ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW).
NYS FORM NF-5 (Rev 6/2013)
Page 2 of 2
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
SIGNATURE OF PATIENT, PARENT OR GUARDIAN (Assignor) DATE
HOSPITAL FACILITY FORM - PAGE 2
THE APPLICANT AUTHORIZES THE INSURER TO SUBMIT ANY AND ALL OF THESE FORMS TO ANOTHER PARTY OR INSURER IF
SUCH IS NECESSARY TO PERFECT ITS RIGHTS OF RECOVERY PROVIDED FOR UNDER THIS ACT. THIS FORM IS SUBSCRIBED
AND AFFIRMED BY THE PATIENT AS TRUE UNDER THE PENALTIES OF PERJURY.
(SIGNATURE OF PATIENT, PARENT OR GUARDIAN) (DATE)
PATIENT: Your health provider may agree to accept payment for health services performed directly from your insurer (Authorization to Pay
Benefits) so that you are not required to make payment to the health provider at the time of service. Such agreement is optional on the part
of the health provider and must be signed by both patient and health provider. You may use the optional authorization language provided
below, by checking off the designated spot in item A of this form.
I AUTHORIZE PAYMENT OF HEALTH BENEFITS TO THE UNDERSIGNED HEALTH CARE PROVIDER OR SUPPLIER OF SERVICES
DESCRIBED BELOW. I RETAIN ALL RIGHTS, PRIVILEGES AND REMEDIES TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE
NO-FAULT PROVISION) OF THE INSURANCE LAW.
(HOSPITAL NAME - Assignee) (HOSPITAL REPRESENTATIVE)
AUTHORIZATION FOR RELEASE OF HEALTH SERVICE OR TREATMENT INFORMATION
SIGNATURE (PATIENT, PARENT OR GUARDIAN) DATE
(SIGNATURE OF PATIENT, PARENT OR GUARDIAN) (SIGNATURE OF HOSPITAL REPRESENTATIVE)
DATE
PATIENT: Your health provider may agree to have you assign your right to No-Fault benefits from your insurer directly to your health provider
(Assignment of Benefits). If you and your health provider agree to an assignment of benefits, you must both sign the agreement contained
in item B or the prescribed NF-AOB form or its equivalent. The language contained in the assignment of benefits is mandatory and may not
be altered or avoided by any other language added to this agreement or other written agreement.
I HEREBY ASSIGN TO THE HEALTH CARE PROVIDER INDICATED ABOVE ALL RIGHTS, PRIVILEGES AND REMEDIES TO
PAYMENT FOR HEALTH CARE SERVICES PROVIDED BY THE ASSIGNEE TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE
NO-
FAULT STATUTE) OF THE INSURANCE LAW. THE ASSIGNEE HEREBY CERTIFIES THAT THEY HAVE NOT RECEIVED ANY
PAYMENT FROM OR ON BEHALF OF THE ASSIGNOR AND SHALL NOT PURSUE PAYMENT DIRECTLY FROM THE ASSIGNOR
FOR SERVICES PROVIDED BY SAID ASSIGNEE FOR INJURIES SUSTAINED DUE TO THE MOTOR VEHICLE ACCIDENT,
NOTWITHSTANDING ANY OTHER AGREEMENT TO THE CONTRARY. THIS AGREEMENT MAY BE REVOKED BY THE ASSIGNEE
WHEN BENEFITS ARE NOT PAYABLE BASED UPON THE ASSIGNOR'S LACK OF COVERAGE AND/OR VIOLATION OF A POLICY
CONDITION DUE TO THE ACTIONS OR CONDUCT OF THE ASSIGNOR.
DATE
DEAR EMPLOYER:
The above named person has applied for benefits under the NEW YORK COMPREHENSIVE MOTOR VEHICLE
INSURANCE REPARATIONS ACT (NO-FAULT LAW) as a result of injuries sustained in a motor vehicle accident on the
date indicated. We understand this person is your employee or former employee. To assist us in determining benefits
that may be due the applicant, please provide us with the answer to the following questions.
PLEASE COMPLETE AND SUBMIT THIS FORM TO OUR CLAIMS REPRESENTATIVE AS SOON
AS POSSIBLE. PLEASE NOTE COMPLETED FORM MUST BE SUBMITTED TO INSURER NO
LATER THAN 90 DAYS AFTER WORK LOSS WAS FIRST INCURRED
Thank you for your cooperation.
1. EMPLOYEE'S OCCUPATION:
2. DATES OF EMPLOYMENT : FROM THROUGH
3. GROSS EARNINGS DURING 52 WEEK PERIOD PRIOR TO ACCIDENT: $
WAGE OR SALARY AS OF DATE OF ACCIDENT:
$$$
NUMBER OF HOURS NORMALLY WORKED PER DAY
NUMBER OF DAYS NORMALLY WORKED PER WEEK
4. DATES ABSENT FOLLOWING ACCIDENT:
FIRST DAY ABSENT FROM WORK
DATE RETURNED TO WORK
5. HAS EMPLOYEE RECEIVED, IS EMPLOYEE RECEIVING OR IS EMPLOYEE ENTITLED TO RECEIVE
BENEFITS UNDER ANY WORKERS' COMPENSATION LAW AS A RESULT OF THIS ACCIDENT?
YES NO
WORKER'S COMPENSATION INSURER
ADDRESS
POLICY NUMBER
NYS FORM NF-6 (Rev 1/2004)
Page 1 of 2
UNDETERMINED
NAME AND ADDRESS OF EMPLOYER*
EMPLOYEE'S NAME, ADDRESS AND SOCIAL
SECURITY NO.
CLAIM REPRESENTATIVE
HOURLY WEEKLY MONTHLY
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
EMPLOYER'S WAGE VERIFICATION REPORT
NAME AND ADDRESS OF INSURER OR SELF-
INSURER*
NAME, ADDRESS, AND PHONE NUMBER OF
INSURER’S CLAIMS REPRESENTATIVE*
6. HAS EMPLOYEE RECEIVED, IS EMPLOYEE RECEIVING OR IS EMPLOYEE ENTITLED TO RECEIVE
NEW YORK STATE DISABILITY BENEFITS AS A RESULT OF THIS ACCIDENT?
YES NO
IS THE EMPLOYEE REQUIRED TO PAY FOR DBL COVERAGE THROUGH PAYROLL DEDUCTION?
YES NO
NYS DISABILITY INSURER
ADDRESS
POLICY NUMBER
7. WAS OR WILL EMPLOYEE BE PAID BY EMPLOYER FOR THIS ABSENCE FROM WORK?
YES NO
IF ANSWER TO QUESTION 7 IS "YES" PLEASE ANSWER QUESTIONS 8, 9, 10 and 11.
8. HOW MUCH WAS OR WILL EMPLOYEE BE PAID $ $
9. WILL THE EMPLOYEE BE REQUIRED TO REIMBURSE YOU ANY OF THE ABOVE AMOUNT?
YES NO
10. WILL THE EMPLOYEE LOSE ACCUMULATED LEAVE CREDITS AS A RESULT OF THE
FOREGOING PAYMENT?
YES NO
11. WILL THE EMPLOYEE'S ELIGIBILITY FOR FUTURE WAGE BENEFITS BE AFFECTED BY PAYMENTS
INDICATED IN QUESTION 8 ABOVE?
YES NO
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-6 (Rev 1/2004)
Page 2 of 2
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY
COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR
CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH
ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF
ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR
AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL
ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE
OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
PRINT NAME
SIGNATURE
TITLE
FEDERAL EMPLOYER I.D. NO.
PHONE NO.
DATE
EMPLOYER'S WAGE VERIFICATION REPORT -- PAGE TWO
UNDETERMINED
WEEKLY MONTHLY
DATE
DEAR APPLICANT:
1. OCCUPATION
2. BUSINESS ADDRESS
3. BUSINESS PHONE
4. NATURE OF BUSINESS OR PROFESSION
5. DATES YOU WERE UNABLE TO ATTEND TO YOUR BUSINESS OR PROFESSION DUE TO
THIS ACCIDENT:
FROM: THROUGH:
6. DID YOU HIRE ANY ONE TO SUBSTITUTE FOR YOU WHILE YOU WERE ABSENT DUE TO
YOUR INJURIES?
YES NO
IF YES, PLEASE COMPLETE THE FOLLOWING:
A. WAGE OR SALARY PAID: $ DAILY $ WEEKLY $ MONTHLY
B. PERIOD SUBSTITUTE EMPLOYED: FROM THROUGH
C. GROSS AMOUNT PAID TO SUBSTITUTE: $
D. NAME, ADDRESS AND PHONE NO. OF SUBSTITUTE:
7. IF ANSWER TO QUESTION 6, WAS "YES", DID YOU SUFFER A NET LOSS OF EARNINGS FROM WORK
IN ADDITION TO THE COST OF SUBSTITUTE SERVICES?
YES NO
IF YES, THE AMOUNT OF NET LOSS CLAIMED: $ FOR THE PERIOD
CLAIMED IN QUESTION 5.
NYS FORM NF-7 (Rev 1/2004)
Page 1 of 2
NAME AND ADDRESS OF APPLICANT*
The information requested below would be used to determine the amount of loss of earnings from work, if any, to which you
may be entitled as a result of this accident. Therefore, it would be in your best interest to complete the form and submit all
documents requested to the best of your ability. Kindly note, depending upon the applicable endorsement in effect at
the time of the accident, this completed form must be submitted to the insurer as soon as reasonably practicable or
no later than 90 days after the work loss was first incurred. If you are unsure of the applicable time requirement, you
can contact the claim representative to determine which timeframe is applicable to this claim.
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
VERIFICATION OF SELF-EMPLOYMENT INCOME
NAME AND ADDRESS OF INSURER OR SELF-
INSURER*
NAME, ADDRESS, AND PHONE NUMBER OF
INSURER’S CLAIMS REPRESENTATIVE*
8. IF ANSWER TO QUESTION 6. WAS "NO", DID YOU SUFFER A NET LOSS OF EARNINGS FROM WORK
DURING YOUR CLAIMED DISABILITY?
YES NO
IF YES, THE AMOUNT OF NET LOSS CLAIMED: $ FOR THE PERIOD
CLAIMED IN QUESTION 5.
9. IN ORDER FOR US TO EVALUATE YOUR CLAIM, IT IS ESSENTIAL THAT YOU SUBMIT COPIES OF YOUR
FEDERAL INCOME TAX RETURNS FOR THE LAST TWO YEARS. IN ADDITION, SUBMIT WHATEVER
DOCUMENTS ARE AVAILABLE TO PROVE YOUR INCOME FOR THE CURRENT YEAR. IF YOU HAVE
NOT FILED EITHER OF THE TAX RETURNS, SUBMIT WHATEVER PROOF OF EARNINGS YOU HAVE
FOR THOSE YEARS THAT YOU FEEL WILL ASSIST US IN EVALUATING YOUR CLAIM.
IF WE ARE UNABLE TO VERIFY YOUR LOSS OF EARNINGS FROM THE DOCUMENTS SUBMITTED,
THE FOLLOWING ADDITIONAL DOCUMENTATION MAY BE REQUESTED.
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-7 (Rev 1/2004)
Page 2 of 2
THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE
APPLICANT AS TRUE UNDER THE PENALTIES OF PERJURY
SIGNATURE OF APPLICANT DATE
VERIFICATION OF SELF-EMPLOYMENT INCOME -- PAGE TWO
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM
FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR
CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH
ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF
ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES
OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND
SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE
VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
DATE
DEAR APPLICANT:
This three
part form must be completed by you and your district Social Security office in order for your No-Fault
loss of earnings benefits to continue without interruption.
I agree to apply for and diligently pursue within 35 days from the date above,
Social Security Disability benefits that may be recoverable on account of injuries caused by this accident.
The applicant further agrees to reimburse the Insurer for any amounts that may have been or may be advanced
by the Insurer pursuant to this agreement, pending receipt of Social Security Disability benefits. The applicant may deduct
from the reimbursement any attorney's fee which he/she paid in order to obtain the Social Security Disability benefits.
(NAME OF INSURER OR SELF-INSURER), upon receipt of this agreement and the Authorization for Release
of Information by the Social Security Administration, both duly signed by the Applicant or the Applicant's legal guardian,
agrees to continue the payment of No-Fault benefits for loss of earnings without deducting amounts recoverable as Social
Security Disability benefits as permitted by Section 5102(b)(2) of the New York Insurance Law, until such Social Security
Disability benefits are received.
In the event that the applicant fails to sign and return this Agreement and Authorization or to apply for Social
Security Disability benefits in accordance with this Agreement within the aforesaid 35 day period, the insurer shall
estimate the amount of monthly Social Security Disability benefits which it believes the applicant would be entitled to
receive and, beginning with the seventh month from the date of accident or 35 calendar days after the agreement was
forwarded to the applicant, in the event the seventh month has passed, the insurer shall deduct the estimated Social
Security Disability benefits from loss of earnings benefits due on account of injuries caused by this accident to the applicant.
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-8 (Rev 1/2004)
Page 1 of 2
SIGNATURE OF INSURER'S REPRESENTATIVE
DATE
DATE
NAME AND ADDRESS OF APPLICANT*
(NAME OF APPLICANT)
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY
COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR
CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER
TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR
VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN
INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL
ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF
THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
SIGNATURE OF APPLICANT
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
AGREEMENT TO PURSUE SOCIAL SECURITY DISABILITY BENEFITS
NAME AND ADDRESS OF INSURER OR SELF-
INSURER*
NAME, ADDRESS, AND PHONE NUMBER OF
INSURER’S CLAIMS REPRESENTATIVE*
I hereby authorize the Social Security Administration to disclose the necessary information, such as my name, account
number, disability benefit rate and date of entitlement to benefits to the person or agency listed below:
Disclose Information to:
This authorization is effective for only as long as is needed to determine my eligibility to benefits and my rate of benefit payment.
Please indicate below the resident D/O for the Disability Claim and the date filed. After doing so, place one copy of this
authorization in file, return two to the claimant and instruct the claimant to forward copy III to the Insurance Company.
COPY I - S.S.A
COPY II - APPLICANT
COPY III - INSURER
NYS FORM NF-8 (Rev 1/2004)
Page 2 of 2
DATE APPLICANT'S SIGNATURE
ATTENTION SOCIAL SECURITY CLAIMS REPRESENTATIVE!!
RESIDENT D/O DATE CLAIM FILED
PAGE TWO
AUTHORIZATION FOR RELEASE OF INFORMATION BY THE SOCIAL SECURITY ADMINISTRATION
NAME OF TITLE II CLAIMANT SOCIAL SECURITY CLAIM NUMBER
AGREEMENT TO PURSUE SOCIAL SECURITY DISABILITY BENEFITS
DATE
IT IS HEREBY AGREED between the Applicant and the Insurer, as follows:
In the event a source of Workers' Compensation or N.Y.S. Disability benefits denies liability for payment of
benefits due on account of the above accident, in whole or in part, the Insurer agrees to process the Applicant's No-Fault
claim without deducting the withheld State or Federal Workers' Compensation benefits or N.Y.S. Disability benefits under
the following conditions:
FIRST: The Applicant executes this Agreement.
SECOND: In the event such amounts are eventually paid to the Applicant, the Applicant agrees to repay the
first party benefits equal to the withheld amounts of Workers' Compensation benefits or N.Y.S. Disability benefits less
any attorney's fee which the Applicant paid in order to obtain the benefits.
THIRD: In the event the Applicant does not reimburse the Insurer, as provided herein, the Insurer may
thereafter deduct such amounts from any future No-Fault benefits due the Applicant on the claim.
FOURTH: The Applicant agrees to diligently pursue any claim for Workers' Compensation or N.Y.S. Disability
benefits.
FIFTH: In the event the Applicant fails to diligently pursue such claim for Workers' Compensation or N.Y.S.
Disability benefits as set forth in Paragraph Fourth or in the event the Applicant fails to reimburse the Insurer as provided
herein, the Insurer may bring an action to recover the amount paid under this agreement.
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-9 (Rev 1/2004)
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
AGREEMENT TO PURSUE WORKERS' COMPENSATION OR N.Y.S. DISABILITY BENEFITS
NAME AND ADDRESS OF INSURER OR SELF-
INSURER*
NAME, ADDRESS, AND PHONE NUMBER OF
INSURER’S CLAIMS REPRESENTATIVE*
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME AND ADDRESS OF APPLICANT*
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM
FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR
CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH
ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF
ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES
OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND
SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE
VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
DATE
DATE
SIGNATURE OF APPLICANT
SIGNATURE OF INSURER
TO INSURER: Complete this form, including item 33. Send two copies to applicant. Upon the request of the injured person, the insurer
should send to the injured person a copy of all prescribed claim forms and documents submitted by or on behalf of the injured person.
YES
NO
YOU ARE ADVISED THAT FOR REASONS NOTED BELOW:
1. Your entire claim is denied as follows:
2. A portion of your claim is denied as follows:
A. Loss of Earnings $ D. Interest $
B. Health Service Benefits
$ E. Attorney's Fee $
C. Other Necessary Expenses $ F. Death Benefit $
3. Policy not in force on date of accident 6. Injured person not an "Eligible Injured Person"
4. Injured person excluded under policy conditions 7. Injuries did not arise out of use or operation of a
or exclusion motor vehicle
5. Policy conditions violated: 8. Claim not within the scope of your election under
a. No reasonable justification given for late Optional Basic Economic Loss coverage
notice of claim
b. Reasonable justification not established--You
may qualify for special expedited arbitration--
See page 2 of this form for instructions.
9. Period of disability contested: period in dispute
11. Exaggerated earnings claim
From_______________Through_____________
of $______________per month denied
10. Claimed loss not proven 12. Statutory offset taken
13. Other, explained below
14. Amount of claim exceeds daily limit of coverage 16. Incurred after one year from date of accident
15. Unreasonable or unnecessary expenses 17. Other, explained below
18. Fees not in accordance with fee schedules 20. Treatment not related to accident
19. Excessive treatment, service or hospitalization 21. Unnecessary treatment, service or hospitalization
From_______________Through_____________ From_______________Through_____________
22. Other, explained below
23. Provider of Health Service (Name, Address and Zip Code) 25. Period of bill - treatment dates 29. Date final verification received
26. Date of bill 30. Amount of bill
$
24. Type of service rendered 27. Date bill received by insurer 31. Amount paid by insurer
$
28. Date final verification requested 32. Amount in dispute
$
33. State reason for denial, fully and explicitly (attach extra sheets if needed):
NYS FORM NF-10 (Rev 5/2021)
Page 1 of 3
Name and address of Insurer claim processor (Third Party Administrator), if applicable
Telephone No. & Ext.
HEALTH SERVICE BENEFITS DENIED
COMPLETE ITEMS 23 THROUGH 32 IF CLAIM FOR HEALTH SERVICE BENEFITS IS DENIED
DATE
Name and Title of Representative of Insurer
Telephone No. & Ext.
REASON(S) FOR DENIAL OF CLAIM (Check reasons and explain below in item 33)
POLICY ISSUES
LOSS OF EARNINGS BENEFITS DENIED
OTHER REASONABLE AND NECESSARY EXPENSES DENIED
E. CLAIM NUMBER
F. APPLICANT FOR BENEFITS (Name and address)
G. AS ASSIGNEE
TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CONTEST THIS DENIAL
A. POLICYHOLDER
B. POLICY NUMBER
C. DATE OF ACCIDENT
D. INJURED PERSON
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
DENIAL OF CLAIM FORM
NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND
ADDRESS OF SELF-INSURER
For American Arbitration Association use
IF YOU WISH TO CONTEST THIS DENIAL, YOU HAVE THE FOLLOWING OPTIONS:
1. Should you wish to take this matter up with the New York State Department of Financial Services, you may file with the Department either on its
website at http://www.dfs.ny.gov/consumer/fileacomplaint.htm or you may write to the Consumer Assistance Unit, New York State Department of
Financial Services, at: One State Street, New York, NY 10004; One Commerce Plaza, Albany, NY 12257; 1399 Franklin Avenue, Garden City, NY 11530;
or 535 Washington Street, Suite 305, Buffalo, NY 14203.
Although the Department of Financial Services will attempt to resolve disputed claims, it cannot order or require an insurer to pay a disputed
claim. If you wish to file a written complaint, send one copy of this Denial of Claim Form with copies of other pertinent documents with a
letter fully explaining your complaint to the Department of Financial Services at one of the above addresses.
If you choose this option, you may at a later date still submit this dispute to arbitration or bring a lawsuit; or
2. You may submit this dispute to arbitration. If you wish to submit this claim to arbitration, then mail or e-mail a copy of this Denial of Claim Form
along with a complete submission of all other pertinent documents and a table of contents listing your submissions, in duplicate
together with a $40 filing fee, payable by check, money order, or credit card to the American Arbitration Association (AAA) to:
AMERICAN ARBITRATION ASSOCIATION (AAA)
NEW YORK INSURANCE CASE MANAGEMENT CENTER
120 BROADWAY
NEW YORK, NEW YORK 10271
nyicmc.filingsubmissions@adr.org
Please contact the American Arbitration Association's customer service department at (917) 438-1660 with any questions about case filing.
Loss of earnings: Date claim made:_____________________ Gross earnings per month $______________________
Period of dispute: From ___________ Through _____________ Amount claimed: $_____________________________
Health Services: (Attach bills in dispute and list each one separately)
Date of Service
Other Necessary Expenses: (Attach bills in dispute and list each one separately)
Amount Claimed
Other: (attach additional sheet if necessary)
NYS FORM NF-10 (Rev 5/2021)
Page 2 of 3
·
Upon your request, if you file for arbitration within 90 days of the date of this denial or the claim becoming overdue, your case will be scheduled for
arbitration on a priority basis.
·
You qualify for special expedited arbitration if the insurer has determined that your written justification for submitting late notice of claim failed to
meet a “reasonableness standard”. Your specific request for special expedited arbitration must be filed within 30 days of the date of denial. Your
filing must be complete and contain all information that you are submitting at the time of filing.
Type of Expenses Claimed
Date Incurred
Date Claim Mailed
Amount in Dispute
If you are contesting the denial of claim and wish to submit the dispute to arbitration, state on accompanying sheets the reason(s) you believe the
denied or overdue benefits should be paid. Attach proof of disability and verification of loss of earnings in dispute, sign below, and send the
completed form to the American Arbitration Association at the address given in item 2 above.
Name of Provider(s)
Amount of Bill
Amount in Dispute
Date Claim Mailed
DENIAL OF CLAIM FORM -- PAGE TWO
A complete copy of this filing, listing all bills and proofs as well as a table of contents listing your submissions must be provided to the AAA and the
insurer at the time of filing for arbitration. The filing must be complete with all necessary documentation, as any late submission may not be
admissible at arbitration. The filing fee will be returned to you if the arbitrator awards you any portion of your claim. However, you may be assessed
the costs of the arbitration proceeding if the arbitrator finds your claim to be frivolous, without factual or legal merit or was filed for the purpose of
harassing the respondent. The decision of an arbitrator is binding, except for limited grounds for review set forth in the Law and regulations
promulgated thereunder.
3. You may bring a lawsuit to recover the amount of benefits you claim to be entitled to.
ARBITRATION REQUESTED BY:
NAME OF LAW FIRM, IF ANY
TELEPHONE NUMBER:
FAX NUMBER:
EMAIL ADDRESS:
ADDRESS
ARE YOU AN ATTORNEY? DATE
YES
NO
SIGNATURE
If box number 3 ("Policy not in force on date of accident") on the front of this form is checked as a reason for this denial, you may be entitled to
No-Fault benefits from the Motor Vehicle Accident Indemnification Corporation (M.V.A.I.C.) (646-205-7800) located at 100 William Street, New York,
New York 10038. The Insurance Law requires that you must file an Affidavit of Intention to Make Claim with M.V.A.I.C. Therefore, it is in
your best interest to contact the M.V.A.I.C. immediately and file such an affidavit, even if you intend to contest this denial.
NYS FORM NF-10 (Rev 5/2021)
Page 3 of 3
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR
PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN
CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS
OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION
OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN
INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE
SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR
VEHICLE OR STATED CLAIM FOR EACH VIOLATION
LAST NAME
FIRST NAME
IMPORTANT NOTICE TO APPLICANT
DENIAL OF CLAIM FORM -- PAGE THREE
THE UNDERSIGNED AFFIRMS AND CERTIFIES AS TRUE UNDER THE PENALTY OF PERJURY THAT THIS FILING IS BEING MADE IN GOOD
FAITH AND THAT UPON INFORMATION, BELIEF AND REASONABLE INQUIRY THE DOCUMENTS BEING SUBMITTED HEREWITH ARE NOT
FRAUDULENT AND THAT EXACT COPIES OF ALL DOCUMENTS PROVIDED HEREWITH HAVE BEEN MAILED TO THE INSURER AGAINST
WHOM THE ARBITRATION IS BEING REQUESTED. UNLESS DISCLOSED WITH THIS SUBMISSION, THE DISPUTED AMOUNTS REMAIN
UNPAID TO THE APPLICANT BY ANY PAYOR AND THERE HAS BEEN NO OTHER FILING OF AN ARBITRATION REQUEST OR LAWSUIT TO
RESOLVE THE DISPUTED MATTERS CONTAINED IN THIS SUBMISSION.
DATE
DEAR APPLICANT:
Kindly complete and return this agreement at once. Failure to do so may delay payment of your No-Fault Benefits.
TO Company
The undersigned hereby declares that a bodily injury was sustained by:
ON
and a claim for extended economic loss benefits (medical, loss of earnings, other reasonable and necessary expenses
and/or a death benefit) is being made under policy number ________________ issued to ________________________
In consideration for benefits paid or payable under the additional personal injury protection endorsement of the foregoing
policy, it is agreed that:
1. In accordance with the provisions of the policy, the company is subrogated to the extent of any payment for
additional first-party benefits to the rights of the applicant against any person because of bodily injury with respect
to which additional personal injury protection benefits are afforded under this policy.
2. The undersigned shall cooperate with the company and upon the company's request, assist in the conduct of suits
and in enforcing any company right of subrogation for additional personal injury protection benefits paid against any
person who may be liable to the injured person because of bodily injury with respect to which additional personal
injury protection benefits are afforded under this policy.
3. The undersigned to or for whom payments are made or the undersigned's legal representative will notify the company
in writing prior to institution of any legal proceedings against any person legally responsible for the above described
bodily injury and will do whatever is necessary to secure and to do nothing to prejudice the company's subrogation rights.
I have read the foregoing subrogation agreement, understand its contents and have signed the same as my free act.
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-11 (Rev 1/2004)
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LA
W
ADDITIONAL PIP SUBROGATION AGREEMEN
T
NAME AND ADDRESS OF INSURER OR SELF-
INSURER*
NAME, ADDRESS, AND PHONE NUMBER OF INSURER’S
CLAIMS REPRESENTATIVE*
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER
PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY
COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION,
OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL
THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY
MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE
REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW
ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS
A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY
NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR
STATED CLAIM FOR EACH VIOLATION.
SIGNATURE OF APPLICANT DATE
NAME AND ADDRESS OF APPLICANT*
SUBROGATION AGREEMENT
(NAME OF INSURER)
(NAME OF APPLICANT) (DATE OF ACCIDENT)
DATE
OF
has applied to
for benefits for loss of earnings from work sustained as a result of injury arising out of the use or operation of a motor vehicle.
Dr. OF
has examined the applicant and has certified in a report executed on _______________, a copy of which is annexed to this
Agreement, that in his medical judgment the applicant's injury will result in a period of disability which will extend for at least 3
years beyond the date of the accident causing the injury. Such report further certifies that a lump-sum settlement of the applicant's
loss of earnings from work will be of material benefit to the applicant occupationally and from a rehabilitative standpoint.
The sole obligation of for the applicant's loss of earnings from work, for a projected period
of disability from the date of this agreement of __________ years, _______________months, shall be the payment of
$_________________, which is the present value of such loss of earnings from work which would otherwise have been
payable during this period computed on the basis of a 6 percent annual interest factor and any other applicable offsets, and
subject to the provisions of Article 51 of the New York Insurance Law and any applicable policy endorsements. A worksheet
setting forth the assumptions and computations utilized in deriving the lump-sum settlement value is attached.
The agreement executed above must be approved either by a court of competent jurisdiction or by an arbitrator. If an arbitrator's
approval is requested, the arbitrator must complete the following for the Lump-Sum Settlement Agreement to be valid:
I, , as Arbitrator appointed pursuant to the provisions of the New York Comprehensive
Motor Vehicle Insurance Reparations Act, having reviewed the foregoing application and supporting documents, do hereby approve
the lump-sum settlement agreed to herein and do direct that it shall be paid.
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-12 (Rev 1/2004)
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
LUMP-SUM SETTLEMENT AGREEMENT
NAME AND ADDRESS OF INSURER OR SELF-INSURER*
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME OF APPLICANT FOR BENEFITS ADDRESS OF APPLICANT
Name and address of Insurer or self-insurer
NAME ADDRESS
NAME OF ARBITRATOR
DATE SIGNATURE OF ARBITRATOR
Name of Insurer or Self-Insurer
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR
PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO,
IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS,
SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR
CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR
VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND
SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF
THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
DATE
DATE
SIGNATURE OF APPLICANT OR APPLICANT'S
AUTHORIZED REPRESENTATIVE
SIGNATURE OF REPRESENTATIVE OF INSURER
Dear No-Fault Claimant:
The injury you sustained in the captioned accident is covered under a policy which includes an additional
$25,000 of basic economic loss coverage ("Optional Basic Economic Loss" or "OBEL" coverage). Our records indicate
that the expenses incurred because of your injuries may come within this additional $25,000 of basic economic loss
coverage. The No-Fault law gives you the opportunity to elect how your want the additional $25,000 of coverage to
be spent.
In order that we may continue to process your claim, please make your designation by placing a check mark
in one of the boxes below, next to the option your wish to elect.
(1) basic economic loss which includes health service expenses, loss of earnings from work,
and other reasonable and necessary expenses; or
(2) loss of earnings from work, less statutory offsets; or
(3) psychiatric, physical or occupational therapy and rehabilitation; or
(4) a combination of options (2) and (3).
Please return this completed form to the insurer or self-insurer at the address given above within 15 calendar
days from the date of this letter. You are advised that if you fail to complete and return this form within the time specified,
it will be assumed that you have elected to apply OBEL coverage to option (1) above. You are further advised that, once
an election is made, it cannot be changed.
(PRINT NAME OF LEGAL REPRESENTATIVE, IF APPLICABLE)
NYS FORM NF-13 (Rev 1/2004)
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LA
W
ELECTION OF OPTION - OPTIONAL BASIC ECONOMIC LOSS COVERAG
E
NAME AND ADDRESS OF INSURER OR SELF-
INSURER*
DATE OF MAILING
NAME AND ADDRESS OF APPLICANT*
POLICYHOLDER
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR
OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM
FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE
INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY
FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR
CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH
ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF
ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES
OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND
SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE
VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
DATED SIGNATURE OF CLAIMANT OR LEGAL REPRESENTATIVE
POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
I, , ("Assignor") hereby assign to , ("Assignee")
(Print hospital or health care provider name)
all rights privileges and remedies to payment for health care services provided by assignee to which I am
entitled under Article 51 (the No-Fault statute) of the Insurance Law.
shall not pursue payment directly from the Assignor for services provided by said Assignee for injuries sustaine
d
due to the motor vehicle accident which occurred on , not withstanding any other agreement
to the contrary.
This agreement may be revoked by the assignee when benefits are not payable based upon the assignor’s lack
of coverage and/or violation of a policy condition due to the actions or conduct of the assignor.
NYS FORM NF-AOB (Rev 1/2004)
(Date of signature)
(Address of Provider)
(Date of signature)
(Address of Patient)
(Print name of Provider) (Signature of Provider)
The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and
(Print accident date)
ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON
FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR
PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE
PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO,
IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS,
SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR
CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR
VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND
SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF
THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION.
(Print name of Patient) (Signature of Patient)
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
ASSIGNMENT OF BENEFITS FORM
(FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/02)
(Print patient's name)
