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Application for Motor Vehicle No-Fault Benefits
hudsonvalleywebgirl
2022-09-07T10:53:10-04:00
New York Motor Vehicle No-Fault Insurance Law Application for Motor Vehicle No-Fault Benefits
Insurance Company Name & Address:
*
Name & Phone # Adjuster
*
Date
*
POLICYHOLDER
*
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 RECEIVED TO DATE.
YOUR NAME
*
PHONE NUMBER
*
PHONE NUMBER
YOUR ADDRESS:
*
DATE OF BIRTH
*
SOCIAL SECURITY #
*
DATE & TIME OF ACCIDENT
*
ADDRESS OF ACCIDENT
*
BRIEF DESCRIPTION OF ACCIDENT:
*
DESCRIBE YOUR INJURY:
*
IDENTITY OF VEHICLE YOU OCCUPIED OR OPERATED AT THE TIME OF THE ACCIDENT:
*
THIS VEHICLE WAS A:
BUS OR SCHOOL BUS
MOTORCYCLE
TRUCK
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
DO YOU OR A RELATIVE WITH WHOM YOU RESIDE OWN A MOTOR VEHICLE?
YES
NO
WERE YOU TREATED BY A DOCTOR(S) OR OTHER PERSON(S) FURNISHING HEALTH SERVICES?
YES
NO
IF YOU WERE TREATED AT A HOSPITAL(S), WERE YOU AN
OUTPATIENT
IN-PATIENT
DATE OF ADMISSION:
HOSPITAL'S NAME & ADDRESS:
AMOUNT OF HEATH BILLS TO DATE:
WILL YOU HAVE MORE HEALTH TREATMENT(S)?
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
DATE ABSENCE FROM WORK BEGAN:
HAVE YOU RETURNED TO WORK?
YES
NO
IF YES, 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 DAY:
WERE YOU RECEIVING UNEMPLOYMENT BENEFITS AT THE TIME OF THE ACCIDENT?
YES
NO
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 & ADDRESS:
OCCUPATION:
FROM:
TO:
EMPLOYER & ADDRESS:
OCCUPATION:
FROM:
TO:
EMPLOYER & ADDRESS:
OCCUPATION:
FROM:
TO:
AS A RESULT OF YOUR INJURY, HAVE YOU HAD ANY OTHER EXPENSES?
YES
NO
IF YES, PLEASE ATTACH EXPLANATION AND AMOUNTS OF SUCH EXPENSES.
Upload file
Choose File
No file chosen
Delete uploaded file
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 RIGHTS 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 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 INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW)
NAME
*
SOCIAL SECURITY #
*
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
*
SIGNATURE:
*
DATE
*
SUBMIT
New York Motor Vehicle No-Fault Insurance Law Application for Motor Vehicle No-Fault Benefits
Insurance Company Name & Address:
*
Name & Phone # Adjuster
*
Date
*
POLICYHOLDER
*
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 RECEIVED TO DATE.
YOUR NAME
*
PHONE NUMBER
*
PHONE NUMBER
YOUR ADDRESS:
*
DATE OF BIRTH
*
SOCIAL SECURITY #
*
DATE & TIME OF ACCIDENT
*
ADDRESS OF ACCIDENT
*
BRIEF DESCRIPTION OF ACCIDENT:
*
DESCRIBE YOUR INJURY:
*
IDENTITY OF VEHICLE YOU OCCUPIED OR OPERATED AT THE TIME OF THE ACCIDENT:
*
THIS VEHICLE WAS A:
BUS OR SCHOOL BUS
MOTORCYCLE
TRUCK
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
DO YOU OR A RELATIVE WITH WHOM YOU RESIDE OWN A MOTOR VEHICLE?
YES
NO
WERE YOU TREATED BY A DOCTOR(S) OR OTHER PERSON(S) FURNISHING HEALTH SERVICES?
YES
NO
IF YOU WERE TREATED AT A HOSPITAL(S), WERE YOU AN
OUTPATIENT
IN-PATIENT
DATE OF ADMISSION:
HOSPITAL'S NAME & ADDRESS:
AMOUNT OF HEATH BILLS TO DATE:
WILL YOU HAVE MORE HEALTH TREATMENT(S)?
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
DATE ABSENCE FROM WORK BEGAN:
HAVE YOU RETURNED TO WORK?
YES
NO
IF YES, 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 DAY:
WERE YOU RECEIVING UNEMPLOYMENT BENEFITS AT THE TIME OF THE ACCIDENT?
YES
NO
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 & ADDRESS:
OCCUPATION:
FROM:
TO:
EMPLOYER & ADDRESS:
OCCUPATION:
FROM:
TO:
EMPLOYER & ADDRESS:
OCCUPATION:
FROM:
TO:
AS A RESULT OF YOUR INJURY, HAVE YOU HAD ANY OTHER EXPENSES?
YES
NO
IF YES, PLEASE ATTACH EXPLANATION AND AMOUNTS OF SUCH EXPENSES.
Upload file
Choose File
No file chosen
Delete uploaded file
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 RIGHTS 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 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 INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW)
NAME
*
SOCIAL SECURITY #
*
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
*
SIGNATURE:
*
DATE
*
SUBMIT
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