Nys Form Nf-2 - New York Motor Vehicle No-Fault Insurance Law Application For Motor Vehicle No-Fault Benefits

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NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS
DATE
POLICYHOLDER
POLICY NUMBER
DATE OF ACCIDENT
CLAIM NUMBER
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.
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.
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:
OWNER'S NAME
MAKE
YEAR
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?
CONTINUATION ON NEXT PAGE
NYS FORM NF-2 (Rev 1/2004)
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