Aaa Form Ar – Fill Out and Use This PDF

New York Motor Vehicle No-Fault Insurance Law Arbitration Request Form, Page 2

Part 2. Requests for Special Handling

Written Submissions Arbitration: (11 NYCRR 65-4.5 (a) provides for arbitration on the basis of written submissions, at the discretion of the arbitrator, if the amount in dispute is less than $2,000.) Are you interested in having this case decided by the arbitrator entirely on the written submissions, without an in-person hearing? Yes___ No___

Are you interested in having a telephone hearing of this case, instead of an in-person hearing? Yes___ No___

Priority Arbitration (90-day): (11 NYCRR 65-4.5 (i) (2) provides for Priority Arbitration in cases where the request for arbitration is made within 90 days after either a denial of claim was received or the claim became overdue, for EACH claim in dispute. A file that qualifies for Priority Arbitration is scheduled within 45 days from the date of transmittal from the conciliation center.)

Are you filing within 90 days after each claim in dispute was denied or became overdue? Yes___ No___

Special Expedited Arbitration (Late Notice): (11NYCRR 65-4.5 (b) provides for Special Expedited Arbitration proceedings for cases that were denied based on failure to submit notice of claim within 30 days after the accident. To qualify you must request Special Expedited Arbitration within 30 days after the mailing of the denial.)

Was the denial of claim based on late notice to the carrier? Yes___ No___

If yes, are you requesting Special Expedited Arbitration? Yes___ No___

Part 3. Claim(s) in Dispute (Please place a check mark next to space where appropriate.)

_____ Medical (If health benefit claims are in dispute, please attach all bills in question (mark as “Exhibit A”), supporting

documentation - reports, findings, narratives, etc. (mark as “Exhibit B”), assignment of benefits, if applicable (mark as “Exhibit C”). If more space is needed, please use AAA Form AR-Sup, on page 4 of this Form AR.)

_____ Other Necessary Expense(s) (Attach bills in dispute as separate exhibit with supporting documentation - If more space is

needed, please use AAA Form AR-Sup, on page 4 of this Form AR.)

Are additional expenses on AAA Form AR-Sup? Yes ____ No ____

AAA Form AR [Effective June 2004]

New York Motor Vehicle No-Fault Insurance Law Arbitration Request Form, Page 3

_____ Interest

Does this arbitration request include all issues known by the applicant/attorney to be in dispute with the insurer? Yes___ No___ If no, attach explanation.

Was a denial issued? Yes___ No___ If yes, attach a copy. If no, please explain on what basis claim was not paid:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

Reason you believe the denied or overdue benefits should be paid:

______________________________________________________________________________________________________

______________________________________________________________________________________________________

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.

The undersigned affirms and certifies as true under the penalty of perjury that this filing is being made in good faith and that upon information, belief and reasonable inquiry the documents being submitted herewith are not fraudulent and that exact copies of all documents provided herewith have been mailed to the insurer against whom the arbitration is being requested. Unless disclosed with this submission, the disputed amounts remain unpaid to the applicant by any payor and there has been no other filing of an arbitration request or lawsuit to resolve the disputed matters contained in this submission.

How to file:

1.Mail the completed form and all requested attachments in duplicate together with a $40.00 filing fee payable to the American Arbitration Association to: American Arbitration Association, New York Insurance Case Management Center, 120 Broadway,

11th Floor, New York, NY 10271.

2.Mail a duplicate copy of this entire filing including all attachments to the insurer against whom you are requesting arbitration and retain a copy for your records.

3.Make sure to include a table of contents and exhibits.

AAA Form AR [Effective June 2004]

New York Motor Vehicle No-Fault Insurance Law Arbitration Request Form, Page 4

AAAForm AR-Sup - Supplemental Information for Part 3

Include this page with your filing only if applicable.

Medical: Please continue from Part 3, Page 2.

Totals:

Any request in which total column is not completed will be returned.

Other Necessary Expenses: Please continue from Part 3, Page 2.

AAA Form AR Sup [Effective June 2004]