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

Download a blank fillable Nys Form Nf-2 - New York Motor Vehicle No-Fault Insurance Law Application For Motor Vehicle No-Fault Benefits in PDF format just by clicking the "DOWNLOAD PDF" button.

Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.

Complete Nys Form Nf-2 - New York Motor Vehicle No-Fault Insurance Law Application For Motor Vehicle No-Fault Benefits with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.

Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.

ADVERTISEMENT

APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS - - PAGE TWO
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?
CONTINUATION ON NEXT PAGE
NYS FORM NF-2 (Rev 1/2004)
Page 2 of 3

ADVERTISEMENT

00 votes

Related Articles

Top 20 Happy Easter Cards And Gift Tags To Download For Free
Top Ten Easter Arts And Crafts Activities For Your Kids
Free Easter Coloring Pages And Easter Printables For Your Kids

Related forms

Nys Form Nf-2 - New York Motor Vehicle No-fault Insurance Law Application For Motor Vehicle No-fault Benefits Nys Form Nf-2 - New York Motor Vehicle No-fault Insurance Law Application For Motor Vehicle No-fault Benefits Legal
Nys Form Nf-aob - New York Motor Vehicle No-fault Insurance Law Assignment Of Benefits Nys Form Nf-aob - New York Motor Vehicle No-fault Insurance Law Assignment Of Benefits Legal
Nys Form Nf-2 - Application For Motor Vehicle No-fault Benefits Nys Form Nf-2 - Application For Motor Vehicle No-fault Benefits Legal
Form Am-2 - New York State Tax Amnesty Application Form Am-2 - New York State Tax Amnesty Application Financial
Form 135 Instructions - New/expanded Business Facility And Enterprise Zone: I Application For Initially Claiming Tax Benefits Form 135 Instructions - New/expanded Business Facility And Enterprise Zone: I Application For Initially Claiming Tax Benefits Financial
Form Ifta-21 - New York State International Fuel Tax Agreement (ifta) Application - 2015 Form Ifta-21 - New York State International Fuel Tax Agreement (ifta) Application - 2015 Financial
Form Nf-2 - Application For Motor Vehicle No-fault Benefits - 2004 Form Nf-2 - Application For Motor Vehicle No-fault Benefits - 2004 Business
Form Mv-994 - Bond Under Section 2105 (d) Of The New York State Vehicle And Traffic Law Form Mv-994 - Bond Under Section 2105 (d) Of The New York State Vehicle And Traffic Law Legal
Form Vs-3 - Dealer Bond Under New York State Vehicle And Traffic Law Section 415(6-b) Form Vs-3 - Dealer Bond Under New York State Vehicle And Traffic Law Section 415(6-b) Legal
New York Motor Vehicle Bill Of Sale New York Motor Vehicle Bill Of Sale Business

Related Categories

Parent category: Legal
Download
Go
Page of 3