NYS Form NF-7 at a glance
What it is: NYS Form NF-7 is the New York Motor Vehicle No-Fault Insurance Law Verification of Self-Employment Income.
Who signs: This form is subscribed and affirmed by the applicant as true under the penalties of perjury.
A filled-in NYS Form NF-7 example: a self-employed florist claims a net loss
How to fill out NYS Form NF-7, box by box
Date, policyholder, policy number and claim number
The information requested on the form would be used to determine the amount of loss of earnings from work, if any, to which you may be entitled as a result of this accident. Complete the form and submit all documents requested to the best of your ability. Depending upon the applicable endorsement in effect at the time of the accident, this completed form must be submitted to the insurer as soon as reasonably practicable or no later than 90 days after the work loss was first incurred. If you are unsure of the applicable time requirement, you can contact the claim representative to determine which timeframe is applicable to this claim.
Fill in DATE, POLICYHOLDER, POLICY NUMBER, DATE OF ACCIDENT and CLAIM NUMBER.
The language marked * is to be filled in by the insurer or self-insurer: the name and address of insurer or self-insurer, the name, address, and phone number of insurer's claims representative and the name and address of applicant.
Boxes 1 to 5: occupation, business and dates unable to attend
In box 1, enter your occupation.
In box 2, enter your business address.
In box 3, enter your business phone.
In box 4, enter the nature of your business or profession.
In box 5, enter the dates you were unable to attend to your business or profession due to this accident, FROM and THROUGH.
Box 6: did you hire anyone to substitute for you
In box 6: did you hire any one to substitute for you while you were absent due to your injuries? YES or NO.
If yes, complete the following: A. wage or salary paid, daily, weekly or monthly; B. period substitute employed, from and through; C. gross amount paid to substitute; D. name, address and phone no. of substitute.
Box 7: net loss in addition to the cost of substitute services
If the answer to question 6 was YES, answer box 7: did you suffer a net loss of earnings from work in addition to the cost of substitute services? If yes, enter the amount of net loss claimed for the period claimed in question 5.
Box 8: net loss during your claimed disability
If the answer to question 6 was NO, answer box 8: did you suffer a net loss of earnings from work during your claimed disability? If yes, the amount of net loss claimed is for the period claimed in question 5.
Signature of applicant and date
At SIGNATURE OF APPLICANT and DATE, sign and date.
More rules for NYS Form NF-7
In order to evaluate your claim, it is essential that you submit copies of your federal income tax returns for the last two years. In addition, submit whatever documents are available to prove your income for the current year. If you have not filed either of the tax returns, submit whatever proof of earnings you have for those years that you feel will assist in evaluating your claim.
Common questions about NYS Form NF-7
Is there a penalty?
Any person who knowingly and with intent to defraud any insurance company or other person files 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, 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. (checked October 21, 2026)
Sources
[1] NYS Form NF-7 (Rev 1/2004), Verification of Self-Employment Income, New York State Department of Financial Services (the Official source link on this page).