AAA Form AR PDF Details

The AAA Form AR, formally the New York Motor Vehicle No-Fault Insurance Law Arbitration Request Form, is used by claimants who choose arbitration to resolve insurance disputes outside of court. It requires complete details about all parties: the applicant, the insurance provider, and the specifics of the claim being disputed.

A wide range of disputes can be arbitrated using this form, including medical bills, other necessary expenses, loss of earnings, and death benefits. Expedited or priority arbitration is available for urgent cases. Before arbitration begins, the AAA encourages conciliation between parties to seek a voluntary settlement. For related arbitration documents, see the AAA subpoena form or the arbitration UM form.

Filing accuracy is critical: the arbitration outcome is binding and may only be appealed on very limited grounds under applicable law. Claims found frivolous or without merit may result in arbitration costs being imposed on the applicant. Ensure all supporting documentation is complete and attached before submission.

QuestionAnswer
Form NameAaa Form Ar
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesMVAIC, 2004, ar 1 form, form ar1

Form Preview Example

MVAIC claim number *

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

If you wish to arbitrate your claim, please complete (print or type) all applicable sections of this form. Optional No-Fault Arbitration is final and binding except for the limited grounds for review set forth in the law and regulations. Upon receipt of this request, the American Arbitration Association will attempt to resolve the dispute by conciliation pursuant to Insurance Department Regulation 11NYCRR 65-4.2 (b) (2) (iii). If the dispute cannot be resolved by conciliation, your case will be forwarded for arbitration. For additional information please visit our website at: www.adr.org, and click on “New York No-Fault” in the right hand column.

Pursuant to Insurance Department Regulation 11NYCRR 65 – 4.2 (b) (3) (i), the applicant shall submit all supporting documentation with their request for arbitration. Submitted documentation must contain a table of contents and exhibits. The applicant must also simultaneously submit all documents to the insurer. Following this original submission of documents, any other documents submitted by the applicant other than bills or claims for ongoing benefits will be marked “LATE SUBMISSION” and will be admitted into the record at the sole discretion of the arbitrator.

Pursuant to Insurance Department Regulation 11NYCRR 65 – 4.5 (t) (1), the arbitrator may impose all administrative costs of arbitration to the applicant or apportion the administrative costs of arbitration between the parties if the arbitrator concludes that the applicant’s arbitration request was frivolous, was without factual or legal merit or was filed for the purpose of harassing the respondent.

Part 1. Parties in Dispute

Applicant for benefits

 

 

 

 

Were benefits assigned to

 

 

 

 

 

provider?

Last name

First name

Address

 

___ Yes ___ No

Injured person

 

 

 

 

Date of accident

Last name

First name

Address

 

 

Policyholder

 

 

 

 

Policy number

Last name

First name

Address

 

 

Insurer or self-insurer

 

 

Insurer’s claims office address

 

 

 

 

 

Insurer’s representative

 

 

Telephone number

Insurer claim or file number

 

 

 

 

 

 

* If bringing arbitration against MVAIC, please provide claim beginning with prefix “P”, if available.

Did the accident occur in New York State? Yes___ No___

If no, is the injured person or a member of their household a New York State Automobile Policy Holder? Yes___ No___

The injured person named above was the ( ) Driver ( ) Passenger ( ) Pedestrian ( ) Bicyclist ( ) Other (Please explain)

_______________________________________________________________________________________________________

_______________________________________________________________________________________________________

Every attempt should be made to resolve this claim with the insurer prior to filing for arbitration. When was the insurer last contacted? ________________

Name and title of person contacted:

_______________________________________________________________________________________________________

AAA Form AR [Effective June 2004]

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.)

Doctor, hospital or other health provider

Amount of each bill

Amount paid

Unpaid or disputed balance

Dates of service

Date bill mailed

Was verification requested No Yes Date supplied

Totals:

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

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

_____ 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.)

Type of expense claimed

Amount claimed

Amount in dispute

Date incurred

Date mailed

Totals:

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

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

Benefit paid late

Amount of bill

Date mailed to insurer

Was verification requested? No Yes Date supplied

Date paid by insurer

_____

Death Benefit

Date death certificate mailed to insurer:

__________

_____

Loss of Earnings

Period in dispute: from: _________ to:

__________

Gross earnings per month: $ _________ Amount claimed: $ __________

Date claim was made: __________

_____

Attorney’s Fee

 

 

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.

Arbitration requested by

 

Name of law firm, if any

 

 

Last name

First name

 

 

 

Telephone number

 

Address

 

Email

 

 

 

 

 

Signature

 

Are you an attorney?

Date

Fax number

 

 

___ Yes ___ No

 

 

 

 

 

 

 

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.

Doctor, hospital or

Amount

Amount

Unpaid or

other health provider

of each

paid

disputed

 

bill

 

balance

 

 

 

 

Dates of service

Date bill mailed

Was verification requested

No Yes Date supplied

Totals:

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

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

Type of expense claimed

Amount claimed

Amount in dispute Date incurred

Date mailed

Totals:

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

AAA Form AR Sup [Effective June 2004]

How to Edit Aaa Form Ar Online for Free

When working in the online PDF editor by FormsPal, you can complete or edit the AAA Form AR right here in your browser. Here is how to get started:

Step 1: Click the "Get Form" button above to open the PDF editor and begin filling in your arbitration request form.

Step 2: The tool lets you customize the form in many ways. Add your information, modify existing entries, and include a digital signature.

To finalize your AAA Form AR, complete the required fields in every section:

1. Enter the applicant and claimant details in the first section, including name, address, and contact information:

How to complete AAA Form AR section 1 - applicant details

2. Complete the insurance details: Insurer representative, Telephone number, Insurer claim or file number, MVAIC claim number, and whether the accident occurred in New York State.

Completing the insurer section of AAA Form AR

3. In Part 1 - Special Bills, enter: Doctor or hospital name, Amount of each bill, Amount paid, Unpaid or disputed balance, Dates of service, Date bill mailed, and whether verification was requested.

Completing Part 1 of AAA Form AR - medical bills

4. In the additional expense sections, fill in all expense types claimed, amounts, dates incurred, and verification details. Double-check unpaid balances and provider information - these fields are the most common source of errors.

Completing additional expense sections of AAA Form AR

5. Complete the final section with all remaining expense types, totals, dates, and additional AAA form items. Missing any required field may result in an incomplete submission.

Final section of AAA Form AR

Step 3: Review all fields before finishing. Click "Done" to finalize your AAA Form AR. Create a free account to save and manage your completed forms in your FormsPal cabinet.

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