No Fault Benefits Application Details

If you're like most Americans, you probably think that the IRS Form 1040 is the only form you need to file your taxes. But what if I told you there was an even shorter form - Form Nf 2 - that could save you time and money? Introduced in 2015, Form Nf 2 is a simplified tax form designed for taxpayers with simple tax returns. If you're eligible to use Form Nf 2, it's definitely worth considering! Check out my blog post to learn more about this new tax form and find out if it's right for you.

Below is the details about the form you were looking for to complete. It will tell you just how long it may need to complete form nf 2, exactly what fields you will have to fill in and several further specific facts.

QuestionAnswer
Form NameForm Nf 2
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other nameshow to no fault application, ny no fault insurance law, form nf2 no fault, ny form nf2

Form Preview Example

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS

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 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.

NAME AND ADDRESS OF APPLICANT*

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, 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 NF-2 (Rev 1/2004)

Page 1 of 3

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

APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS - - PAGE THREE

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 NO-FAULT LAW.

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

 

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 (NO-FAULT LAW).

NAME (PRINT OR TYPE)

 

SOCIAL SECURITY NO.

 

 

 

SIGNATURE

 

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, X-RAYS AND PHYSICAL FINDINGS, DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW).

NAME (PRINT OR TYPE)

SIGNATURE

 

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 SELF-INSURER. NYS FORM NF-2 (Rev 1/2004)

Page 3 of 3

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