In the state of New York, individuals who find themselves in the aftermath of a motor vehicle accident have a crucial ally in the form of the New York Motor Vehicle No-Fault Insurance Law. This legislation not only simplifies the process of seeking compensation for accident-related expenses but also aims to ensure timely assistance. Central to this process is the New York State Form NF-2, an Application for Motor Vehicle No-Fault Benefits, which serves as a comprehensive tool for victims to initiate their claims. When completed, this form provides insurers with the necessary information to determine eligibility for no-fault benefits. Key sections of this form include personal identification details, specifics about the accident, and a detailed account of the injuries sustained. Additionally, it addresses the treatment received and any loss of earnings, thereby offering a thorough picture of the incident and its repercussions. It’s imperative for claimants to fill out the form accurately and provide any required documentation, such as bills for medical treatment and evidence of lost wages, to support their claim. Moreover, the form includes strict disclaimers regarding the submission of false information, underscoring the severity of insurance fraud. By signing the NF-2 form, applicants authorize the release of pertinent employment and medical treatment information, ensuring that insurers have access to all relevant data. This structured approach, mandated by the New York Comprehensive Motor Vehicle Insurance Reparations Act, significantly aids individuals in navigating the potentially complex post-accident landscape.
| Question | Answer |
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| Form Name | Form Nf 2 |
| Form Length | 3 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 45 sec |
| Other names | new york form nf2, motor vehicle no fault, ny no fault insurance law, ny form nf2 |
NEW YORK MOTOR VEHICLE
NAME AND ADDRESS OF INSURER *
NAME, ADDRESS, AND PHONE NUMBER OF INSURER’S
CLAIMS REPRESENTATIVE*
DATE
POLICYHOLDER
POLICY NUMBER
DATE OF ACCIDENT
CLAIM NUMBER
TO ENABLE US TO DETERMINE IF YOUR ARE ENTITLED TO BENEFITS UNDER THE NEW YORK
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*
1. YOUR NAME |
2. PHONE NOS. |
HOME |
BUSINESS |
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3. YOUR ADDRESS |
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4. DATE OF BIRTH |
5. SOCIAL SECURITY NO. |
(NO., STREET, CITY OR TOWN AND ZIP CODE) |
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6. DATE AND TIME OF ACCIDENT |
7. PLACE |
OF ACCIDENT (STREET), CITY OR TOWN AND STATE |
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A.M. |
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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, OR A MOTORCYCLE
A TRUCK,
AN AUTOMOBILE,
YESNO
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
Page 1 of 3
APPLICATION FOR MOTOR VEHICLE
12. WERE YOU TREATED BY A DOCTOR(S) OR OTHER PERSON(S) FURNISHING HEALTH SERVICES?
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YES |
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NO |
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IF YES, NAME AND ADDRESS OF SUCH DOCTOR(S) OR PERSON(S): |
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13. IF YOUR WERE TREATED AT A HOSPITAL(S), WERE YOU AN |
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DATE OF ADMISSION: |
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HOSPITAL'S NAME AND ADDRESS: |
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14. AMOUNT OF HEALTH |
15. WILL YOU HAVE MORE HEALTH |
16. AT THE TIME OF YOUR ACCIDENT WERE |
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BILLS TO DATE: |
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TREATMENT(S)? |
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YOU IN THE COURSE OF YOUR |
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YES |
NO |
EMPLOYMENT? |
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NO |
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17. DID YOU LOSE TIME |
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DATE ABSENCE FROM |
HAVE YOU RETURNED TO |
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FROM WORK? |
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WORK BEGAN: |
WORK? |
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NO |
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IF YES, DATE RETURNED TO |
WORK: |
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OF TIME LOST FROM WORK: |
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18. WHAT ARE YOUR GROSS AVERAGE NUMBER OF DAYS |
YOU WORK |
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NUMBER OF HOURS YOU WORK |
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WEEKLY EARNINGS? |
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PER DAY: |
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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 |
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OCCUPATION |
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TO |
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EMPLOYER AND ADDRESS |
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OCCUPATION |
FROM |
TO |
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EMPLOYER AND ADDRESS |
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OCCUPATION |
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21. AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES? |
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YES |
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NO |
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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
Page 2 of 3
APPLICATION FOR MOTOR VEHICLE
THE APPLICANT AUTHORIZES THE INSURER TO SUBMIT ANY AND ALL OF THESE FORMS TO ANOTHER PARTY OR INSURER IF SUCH IS NECESSARY TO PERFECT ITS RIGHTS OF RECOVERY PROVIDED FOR UNDER THE
THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE
APPLICANT AS TRUE UNDER THE PENALTIES OF PERJURY
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.
SIGNATURE |
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DATE |
DO NOT DETACH
AUTHORIZATION FOR RELEASE OF WORK AND OTHER LOSS INFORMATION
THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY WAGES, SALARY OR OTHER LOSS WHILE EMPLOYED BY YOU. YOUR ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT
NAME (PRINT OR TYPE) |
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SOCIAL SECURITY NO. |
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SIGNATURE |
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DATE |
DO NOT DETACH
AUTHORIZATION FOR RELEASE OF HEALTH SERVICE OR TREATMENT INFORMATION
THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED,
NAME (PRINT OR TYPE)
SIGNATURE |
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DATE |
(IF THE APPLICANT IS A MINOR, PARENT OR GUARDIAN SHALL SIGN AND INDICATE CAPACITY AND RELATIONSHIP).
*LANGUAGE TO BE FILLED IN BY INSURER OR
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