Nf 6 Employer'S Wage Verification Form Details

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.

QuestionAnswer
Form NameForm Nf 6
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesnys form nf 6, geico form nf 6, form no fault verification, nys nf 6

Form Preview Example

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW

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 (NO-FAULT LAW) as a result of injuries sustained in a motor vehicle accident on the date indicated. We understand this person is your employee or former employee. To assist us in determining benefits that may be due the applicant, please provide us with the answer to the following questions.

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

 

 

 

 

 

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

 

NO

WORKER'S COMPENSATION INSURER ADDRESS

POLICY NUMBER

UNDETERMINED

NYS FORM NF-6 (Rev 1/2004)

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EMPLOYER'S WAGE VERIFICATION REPORT -- PAGE TWO

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

$

$

 

 

WEEKLY

 

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

 

TITLE

 

PHONE NO.

 

 

 

 

 

SIGNATURE

 

FEDERAL EMPLOYER I.D. NO.

 

DATE

*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER. NYS FORM NF-6 (Rev 1/2004)

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