Form Nf-2 - Application For Motor Vehicle No-Fault Benefits - 2004
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2NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS
*
NAME AND ADDRESS OF INSURANCE CARRIER
POLICY NUMBER
DATE
POLICY HOLDER
CLAIM NUMBER
DATE OF ACCIDENT
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.
*
NAME AND ADDRESS OF APPLICANT
_________________________________________________________________________________
_________________________________________________________________________________
_________________________________________________________________________________
2. PHONE NOS.
HOME
1. YOUR NAME
BUSINESS
3. YOUR ADDRESS (NO., STREET, CITY OR TOWN AND ZIP CODE)
4. DATE OF BIRTH
5. SOCIAL SECURITY NO.
6. DATE AND TIME OF ACCIDENT
A.M.
7. PLACE OF ACCIDENT (STREET), CITY OR TOWN AND STATE
P.M.
8. BRIEF DESCRIPTION OF ACCIDENT:
9. DESCRIBE YOUR INJURY:
10. IDENTITY OF VEHICLE YOU OCCUPIED OR OPERATED AT THE TIME OF
11. WERE YOU THE DRIVER OF THE MOTOR VEHICLE?
YES
NO
ACCIDENT:
OWNER'S NAME
YEAR
MAKE
WERE YOU A PASSENGER IN THE MOTOR VEHICLE?
YES
NO
WERE YOU A PEDESTRIAN?
YES
NO
THIS VEHICLE WAS:
WERE YOU A MEMBER OF OUR POLICYHOLDER'S HOUSEHOLD?
YES
NO
A BUS OR SCHOOL BUS
A TRUCK, OR
DO YOU OR A RELATIVE WITH WHOM YOU RESIDE OWN A MOTOR
VEHICLE?
YES
NO
A MOTORCYCLE
AN AUTOMOBILE
12. WERE YOU TREATED BY A DOCTOR(S) OR OTHER PERSON(S) FURNISHING HEALTH SERVICES?
YES
NO
NAME AND ADDRESS OF SUCH DOCTOR(S) OR PERSON(S):
IN-PATIENT
13. IF YOU WERE TREATED AT A HOSPITAL(S), WERE YOU AN: OUT-PATIENT
HOSPITAL'S NAME AND ADDRESS:
DATE OF ADMISSION:
14. AMOUNT OF HEALTH BILLS TO DATE
15. WILL YOU HAVE MORE HEALTH
16. AT THE TIME OF YOUR ACCIDENT WERE YOU IN THE COURSE OF YOUR
TREATMENTS(S)
EMPLOYMENT?
YES
NO
YES
NO
$
17. DID YOU LOSE TIME FROM WORK?
DATE ABSENCE FROM WORK BEGAN:
HAVE YOU RETURNED TO WORK?
IF YES, DATE RETURNED TO WORK:
NO
YES
NO
YES
NUMBER OF DAYS YOU WORK PER WEEK:
AMOUNT OF TIME LOST FROM WORK:
18. WHAT ARE YOUR AVERAGE WEEKLY
NUMBER OF HOURS YOU WORK PER DAY:
EARNINGS?
YES
NO
19. WERE YOU RECEIVING UNEMPLOYMENT BENEFITS AT THE TIME OF THE ACCIDENT?
(Continued on next page)
BRACKETED LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-2 (Rev. 1/2004)
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