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
ELECTION OF OPTION - OPTIONAL BASIC ECONOMIC LOSS COVERAG
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
NAME AND ADDRESS OF INSURER OR
SELF-INSURER*
NAME AND ADDRESS OF APPLICANT*
click to sign
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