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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
Schools, Parks, and 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
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 Application
2019-10-01T12:24:37-04:00
New York Motor Vehicle No Fault Insurance Law Application For Motor Vehicle No-Fault Benefits
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
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
State
ZIP Code
Date of Birth
*
Social Security Number
*
Date of Accident
*
Time of Accident
*
:
HH
MM
AM
PM
AM/PM
Place of Accident
*
Street Address
City
Alabama
Alaska
American Samoa
Arizona
Arkansas
California
Colorado
Connecticut
Delaware
District of Columbia
Florida
Georgia
Guam
Hawaii
Idaho
Illinois
Indiana
Iowa
Kansas
Kentucky
Louisiana
Maine
Maryland
Massachusetts
Michigan
Minnesota
Mississippi
Missouri
Montana
Nebraska
Nevada
New Hampshire
New Jersey
New Mexico
New York
North Carolina
North Dakota
Northern Mariana Islands
Ohio
Oklahoma
Oregon
Pennsylvania
Puerto Rico
Rhode Island
South Carolina
South Dakota
Tennessee
Texas
Utah
U.S. Virgin Islands
Vermont
Virginia
Washington
West Virginia
Wisconsin
Wyoming
Armed Forces Americas
Armed Forces Europe
Armed Forces Pacific
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
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