NY Motor Vehicle No Fault Insurance Application

Name of Insurer*

Address of Insurer*

Name of Insurer's Claims Representative*

Address of Insurer's Claims Representative*

Phone Number of Insurer's Claims Representative*

Policyholder*

Date*

Policy Number*

Date of Accident*

Claim Number*

To enable us to determine if you are entitled to benefits under the New York No-Fault law. Please complete this form and return it promptly.

Important: 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 recieved to date.

Name of Applicant*

Address of Applicant*

Phone Number (Cell)*

Phone Number (Home)

Phone Number (Business)

Your Address*

Street Address City State ZIP Code

Date of Birth*

Social Security Number*

Date of Accident*

Time of Accident*

: HH

MM

Place of Accident*

Street Address City State ZIP Code

Brief description of Accident*

Describe your Injury*

Identity of vehicle you occupied or displayed at the time of the accident.

Owner's Name*

Make*

Model*

This Vehicle was*

A Bus or School Bus
A Motorcycle
A Truck
An Automobile

Were you the driver of the motor vehicle?*

YES
NO

Were you a passenger in the motor vehicle?*

YES
NO

Were you a pedestrian?*

YES
NO

Were you a member of our policyholder's household?*

YES
NO

Did you or a relative with whom you reside own a motor vehicle?*

YES
NO

Application For Motor Vehicle No-fault Benefits

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)

Doctor's Name*

Doctor's Address

If you were treated at a hospital(s), were you an*

OUT-PATIENT
IN-PATIENT
NOT TREATED AT HOSPITAL

Date of admission

Hospital Name

Hospital Address

Amount of Health bills to date*

Will you have more health treatments?*

YES
NO

At the time of your accident were you in the course of your employment?*

YES
NO

Did you lose time from work?*

YES
NO

Have you returned from work?*

YES
NO

Date absence from work began

Date returned to work

Amount of time lost from work

What are your gross average weekly earnings?*

Number of Days you work per week*

Number of hours you work per week*

Were you receiving unemployment benefits at the time of the accident?*

YES
NO

List Name and Address of your employer and other employers for one year prior to accident date and give occupation and dates of employment.

Employer

Employer Address

Occupation

From

To

Employer

Employer Address

Occupation

From

To

Employer

Employer Address

Occupation

From

To

As a result of your injury have you had any other expenses?*

YES
NO

What expense and how much did it cost you?*

Due to this accident have you received or are you eligible for payments under any of the following

New York State Disability?*

YES
NO

Workers Compensation?*

YES
NO

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 right of recovery provided for under the No-Fault Law

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 vehicles or 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*

Date*

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. You are authorized to provide this in accordance with the New York comprehensive motor vehicle insurance reparations act (No-Fault Law).

Name*

Social Security Number*

Signature*

Date*

Authorization for release of health service or treatment information.

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*

Date*

Signature*

(If the applicant is a minor, parent or guardian shall sign and indicate capacity and relationship)

Parent or Guardian Capacity and Relationship

Parent/Guardian Signature

CAPTCHA

New York Motor Vehicle No Fault Insurance Law Application For Motor Vehicle No-Fault Benefits

To enable us to determine if you are entitled to benefits under the New York No-Fault law. Please complete this form and return it promptly.

Identity of vehicle you occupied or displayed at the time of the accident.

Application For Motor Vehicle No-fault Benefits

List Name and Address of your employer and other employers for one year prior to accident date and give occupation and dates of employment.

Due to this accident have you received or are you eligible for payments under any of the following

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 right of recovery provided for under the No-Fault Law

This form is subscribed and affirmed by the applicant as true under the penalties of perjury

Authorization for release of work and other loss information

Authorization for release of health service or treatment information.

(If the applicant is a minor, parent or guardian shall sign and indicate capacity and relationship)