Fillable NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION (Plymouth Rock Assurance)

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NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION (Plymouth Rock Assurance)

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The NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION (Plymouth Rock Assurance) form is 3 pages long and contains:

  • 3 signatures
  • 12 check-boxes
  • 67 other fields

Country of origin: US
File type: PDF

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DATE
IMPORTANT:
1. YOUR NAME 2. PHONE NOS. HOME BUSINESS
3.
YOUR ADDRESS 4. DATE OF BIRTH
5. SOCIAL SECURITY NO.
(NO., STREET, CITY OR TOWN AND ZIP CODE)
6. DATE AND TIME OF ACCIDENT 7. PLACE OF ACCIDENT (STREET), CITY OR TOWN AND STATE
A.M.
P.M.
8. BRIEF DESCRIPTION OF ACCIDENT
9.
DESCRIBE YOUR INJURY
10.
IDENTITY OF VEHICLE YOU OCCUPIED OR OPERATED AT THE TIME OF THE ACCIDENT:
THIS VEHICLE WAS: A BUS OR SCHOOL BUS, A TRUCK, AN AUTOMOBILE,
OR A MOTORCYCLE
YES NO
11. WERE YOU THE DRIVER OF THE MOTOR VEHICLE?
WERE YOU A PASSENGER IN THE MOTOR VEHICLE?
WERE YOU A PEDESTRIAN?
WERE YOU A MEMBER OF OUR POLICYHOLDER’S HOUSEHOLD?
DO YOU OR A RELATIVE WITH WHOM YOU RESIDE OWN A MOTOR VEHICLE?
NYS FORM NF-2 (Rev 1/2004)
Page 1 of 3
CONTINUATION ON NEXT PAGE
NAME AND ADDRESS OF APPLICANT*
OWNER'S NAME
MAKE YEAR
TO ENABLE US TO DETERMINE IF YOUR ARE ENTITLED TO BENEFITS UNDER THE NEW YORK NO-FAULT LAW,
PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY.
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.
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS
NAME AND ADDRESS OF INSURER*
NAME, ADDRESS, AND PHONE NUMBER OF
INSURER’S CLAIMS REPRESENTATIVE*
12. 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):
13. IF YOUR WERE TREATED AT A HOSPITAL(S), WERE YOU AN
OUT-PATIENT? IN-PATIENT?
DATE OF ADMISSION:
HOSPITAL'S NAME AND ADDRESS:
14. AMOUNT OF HEALTH 15. WILL YOU HAVE MORE HEALTH 16. AT THE TIME OF YOUR ACCIDENT WERE
BILLS TO DATE: TREATMENT(S)? YOU IN THE COURSE OF YOUR
YES NO EMPLOYMENT?
$ YES NO
17. DID YOU LOSE TIME DATE ABSENCE FROM HAVE YOU RETURNED TO
FROM WORK? WORK BEGAN: WORK?
YES NO YES NO
IF YES, DATE RETURNED TO WORK: AMOUNT OF TIME LOST FROM WORK:
18. WHAT ARE YOUR GROSS AVERAGE NUMBER OF DAYS YOU WORK NUMBER OF HOURS YOU WORK
WEEKLY EARNINGS? PER WEEK: PER DAY:
19. WERE YOU RECEIVING UNEMPLOYMENT BENEFITS AT THE TIME OF THE ACCIDENT?
YES NO
20. 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 AND ADDRESS OCCUPATION FROM TO
EMPLOYER AND ADDRESS OCCUPATION FROM TO
EMPLOYER AND ADDRESS OCCUPATION FROM TO
21. AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES?
YES NO
IF YES, ATTACH EXPLANATION AND AMOUNTS OF SUCH EXPENSES.
22. DUE TO THIS ACCIDENT HAVE YOU RECEIVED OR ARE YOU ELIGIBLE FOR PAYMENTS
UNDER ANY OF THE FOLLOWING:
YES NO
NEW YORK STATE DISABILITY?
WORKERS' COMPENSATION?
NYS FORM NF-2 (Rev 1/2004)
Page 2 of 3
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS - - PAGE TWO
CONTINUATION ON NEXT PAGE
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.
(IF THE APPLICANT IS A MINOR, PARENT OR GUARDIAN SHALL SIGN AND INDICATE CAPACITY AND RELATIONSHIP).
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-2 (Rev 1/2004)
Page 3 of 3
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 (PRINT OR TYPE)
SIGNATURE DATE
SIGNATURE DATE
DO NOT DETACH
AUTHORIZATION FOR RELEASE OF HEALTH SERVICE OR TREATMENT INFORMATION
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. YOUR ARE AUTHORIZED TO
PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE
INSURANCE REPARATIONS ACT (NO-FAULT LAW).
NAME (PRINT OR TYPE) SOCIAL SECURITY NO.
SIGNATURE DATE
DO NOT DETACH
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.
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS - - PAGE THREE
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NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION (Plymouth Rock Assurance)

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Completed 3 August 2021

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