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  • Contact
  • en español
  • Home
  • About
    • Our Team
    • Our Locations
    • News
    • Reviews
    • Service Areas
      • Staten Island, NY
      • Brooklyn, NY
      • Manhattan, NY
      • New Jersey
  • Personal Injury
    • Slip and Falls, and Trip and Falls
    • ACCIDENT F.A.Q’s
    • Auto, Bus, & Train Accidents
    • Motorcycle Accident
    • Tractor-Trailer Accidents
    • Hit and Run Help
    • Uninsured Motorist Claims
    • Dog Bites
    • Construction Accidents
    • Sexual Harassment
    • Medical Malpractice
    • Burn Victims
    • Nursing Home Neglect and Abuse
    • School/ Park/ Playgrounds
    • Casino Slips and Falls
    • Worker’s Compensation
  • Social Security Disability
    • Social Security Disability
    • What Is SSD?
    • SSD F.A.Q’s
    • SSD vs. SSI?
    • Does Marriage Or Divorce Affect SSD?
    • Survivor Benefits
    • How Do You Determine Your “Onset Date”?
    • What Does It Take To Be Insured?
    • What Is “Functional Impairment”?
    • What Is Residual Functional Capacity?
    • Why Are Most Initial Applications Denied?
    • Coronavirus and SSD
    • Criminal Defense
  • Settlements
  • Long-Term Disability
  • Mass Torts
    • 3M Military Earplugs Lawsuit
    • Belviq Cancer Lawsuits
    • Elmiron Eye Disease Lawsuits
    • JUUL Nicotine Addiction Lawsuits
    • Zantac Cancer Lawsuits
  • Contact
  • en español
NY Motor Vehicle No Fault Insurance Application2019-10-01T12:24:37-04:00

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.

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

  • Application For Motor Vehicle No-fault Benefits

    If YES, Name and address of such Doctor(s) or person(s)
  • 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

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

Form Quick Links

  • Vehicle Accident Intake
  • Form Downloads
espanol

Staten Island Locations

3309 Richmond Ave.
SI, NY 10312
Tel: (718) 967-1600
Fax: (718) 967-8677

2555 Richmond Ave
(Next to SI Mall)
SI, NY 10314
Tel: (718) 967-1600

622 Barlow Ave
SI, NY 10312
Tel: (718) 967-1600

New York Locations

275 Madison Ave 35th Floor
New York, NY 10016
Tel: (888) 24-LAW-24

8304 13th Ave.
Brooklyn, NY 11228
Tel: (718) 967-1600

New Jersey Locations

8 Broad Street
Freehold, NJ 07728
Tel: (732) 817-0140

855 Valley Road
Clifton, NJ

Tennessee Location

1016-A 13th Avenue
South Nashville, TN 37212
Tel: (732) 817-0140

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