Form NF 6 is the sixth of many forms that taxpayers use to report their income, deductions, and credits. This form is used by individuals who have self-employment income, farm income, or fishing income. The form is also used by partnerships and S corporations to report their distributive shares of taxable income and tax credits. Taxpayers use this form to calculate their net profit or loss from self-employment activities. The form can also be used to figure out your adjusted gross income (AGI) for self-employment tax purposes.
This article holds information about form nf 6. It is really worth finding the time to study this just before you start submitting your document.
| Question | Answer |
|---|---|
| Form Name | Form Nf 6 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | nys form nf 6, geico form nf 6, form no fault verification, nys nf 6 |
NEW YORK MOTOR VEHICLE
EMPLOYER'S WAGE VERIFICATION REPORT
NAME AND ADDRESS OF INSURER OR SELF-
INSURER*
NAME, ADDRESS, AND PHONE NUMBER OF INSURER’S CLAIMS REPRESENTATIVE*
DATE
POLICYHOLDER
POLICY NUMBER
DATE OF ACCIDENT
CLAIM NUMBER
NAME AND ADDRESS OF EMPLOYER*
DEAR EMPLOYER:
EMPLOYEE'S NAME, ADDRESS AND SOCIAL
SECURITY NO.
The above named person has applied for benefits under the NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT
PLEASE COMPLETE AND SUBMIT THIS FORM TO OUR CLAIMS REPRESENTATIVE AS SOON AS POSSIBLE. PLEASE NOTE COMPLETED FORM MUST BE SUBMITTED TO INSURER NO
LATER THAN 90 DAYS AFTER WORK LOSS WAS FIRST INCURRED
Thank you for your cooperation.
CLAIM REPRESENTATIVE
1.EMPLOYEE'S OCCUPATION:
2. |
DATES OF EMPLOYMENT : |
FROM |
THROUGH |
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3.GROSS EARNINGS DURING 52 WEEK PERIOD PRIOR TO ACCIDENT: WAGE OR SALARY AS OF DATE OF ACCIDENT:
$$
HOURLYWEEKLY
NUMBER OF HOURS NORMALLY WORKED PER DAY
NUMBER OF DAYS NORMALLY WORKED PER WEEK
4.DATES ABSENT FOLLOWING ACCIDENT: FIRST DAY ABSENT FROM WORK DATE RETURNED TO WORK
$
$
MONTHLY
5.HAS EMPLOYEE RECEIVED, IS EMPLOYEE RECEIVING OR IS EMPLOYEE ENTITLED TO RECEIVE BENEFITS UNDER ANY WORKERS' COMPENSATION LAW AS A RESULT OF THIS ACCIDENT?
YES |
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NO |
WORKER'S COMPENSATION INSURER ADDRESS
POLICY NUMBER
UNDETERMINED
NYS FORM
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EMPLOYER'S WAGE VERIFICATION REPORT
6.HAS EMPLOYEE RECEIVED, IS EMPLOYEE RECEIVING OR IS EMPLOYEE ENTITLED TO RECEIVE NEW YORK STATE DISABILITY BENEFITS AS A RESULT OF THIS ACCIDENT?
YES
NO
UNDETERMINED
IS THE EMPLOYEE REQUIRED TO PAY FOR DBL COVERAGE THROUGH PAYROLL DEDUCTION?
YES
NYS DISABILITY INSURER ADDRESS
POLICY NUMBER
NO
7.WAS OR WILL EMPLOYEE BE PAID BY EMPLOYER FOR THIS ABSENCE FROM WORK?
YES
NO
IF ANSWER TO QUESTION 7 IS "YES" PLEASE ANSWER QUESTIONS 8, 9, 10 and 11.
8. |
HOW MUCH WAS OR WILL EMPLOYEE BE PAID |
$ |
$ |
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WEEKLY |
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MONTHLY |
9.WILL THE EMPLOYEE BE REQUIRED TO REIMBURSE YOU ANY OF THE ABOVE AMOUNT?
YES
NO
10.WILL THE EMPLOYEE LOSE ACCUMULATED LEAVE CREDITS AS A RESULT OF THE FOREGOING PAYMENT?
YES
NO
11.WILL THE EMPLOYEE'S ELIGIBILITY FOR FUTURE WAGE BENEFITS BE AFFECTED BY PAYMENTS INDICATED IN QUESTION 8 ABOVE?
YES
NO
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.
PRINT NAME |
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PHONE NO. |
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SIGNATURE |
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FEDERAL EMPLOYER I.D. NO. |
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DATE |
*LANGUAGE TO BE FILLED IN BY INSURER OR
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