When individuals are involved in a motor vehicle accident in New York, the process of claiming no-fault benefits can be intricate and requires thorough documentation. Among the essential forms required is the Wage Loss Verification form, a critical document designed to verify the financial impact of the accident on the victim's earning capacity. This form is a vital part of the application process for motor vehicle no-fault benefits under the New York No-Fault Law, aiming to provide insurers with detailed information about the policyholder, including personal details, details of the accident, and the consequent wage loss experienced due to injuries sustained. It asks for comprehensive details ranging from the policyholder’s identity, accident specifics, healthcare treatments received, to the intricate aspects of wage loss and employment information prior and subsequent to the accident. Additionally, it inquires about any other benefits the applicant might be receiving. This document must be completed accurately and submitted promptly as it plays a significant role in determining the eligibility and extent of benefits under the no-fault insurance coverage. The form also includes sections for authorization for the release of work and health service or treatment information, emphasizing the seriousness of providing truthful information under the penalties of perjury, underscoring the legal implications of fraudulence.
| Question | Answer |
|---|---|
| Form Name | Wage Loss Verification Form |
| Form Length | 7 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 1 min 45 sec |
| Other names | nf 2 form, form nf 2, nys nf 3, form 3 no fault |
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 |
3. YOUR ADDRESS
(NO., STREET, CITY OR TOWN AND ZIP CODE)
4. DATE OF BIRTH
5. SOCIAL SECURITY NO.
6. DATE AND TIME OF ACCIDENT |
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7. PLACE OF ACCIDENT (STREET), CITY OR TOWN AND STATE |
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A.M. |
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P.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?
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 |
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DATE OF ADMISSION: |
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HOSPITAL'S NAME AND ADDRESS: |
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14. AMOUNT OF HEALTH |
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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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NO |
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IF YES, DATE RETURNED TO WORK:
AMOUNT OF TIME LOST FROM WORK:
18.WHAT ARE YOUR AVERAGE WEEKLY EARNINGS?
NUMBER OF DAYS YOU WORK PER WEEK:
NUMBER OF HOURS YOU WORK 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 |
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OCCUPATION |
FROM |
TO |
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EMPLOYER AND ADDRESS |
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OCCUPATION |
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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)
SIGNATURE
SOCIAL SECURITY NO.
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
Page 3 of 3
NEW YORK MOTOR VEHICLE
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
(This form is not for verification of hospital treatment )
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
PROVIDER'S NAME AND ADDRESS*
KINDLY COMPLETE AND SUBMIT THIS FORM AS SOON AS POSSIBLE. PLEASE NOTE, THIS
COMPLETED FORM MUST BE SUBMITTED TO THE INSURER AS SOON AS REASONABLY POSSIBLE BUT NO LATER THAN 45 DAYS OR 180 DAYS AFTER TREATMENT DATE, DEPENDING UPON THE POLICY ENDORSEMENT IN EFFECT AT THE TIME OF THE ACCIDENT. IF YOU ARE UNSURE OF THE APPLICABLE TIME REQUIREMENT, KINDLY CONTACT THE CLAIMS REPRESENTATIVE TO DETERMINE WHICH DEADLINE IS APPLICABLE TO THIS CLAIM.
IF YOU HAVE PREVIOUSLY SUBMITTED AN EARLIER REPORT ON THIS ACCIDENT, YOU NEED ONLY NOTE ANY CHANGES FROM THE INFORMATION PREVIOUSLY FURNISHED AND ADDITIONAL CHARGES.
1. PATIENT'S NAME AND ADDRESS
2. DATE OF BIRTH
3. SEX
4. OCCUPATION (IF KNOWN)
5. DIAGNOSIS AND CONCURRENT CONDITIONS
6.WHEN DID SYMPTOMS FIRST APPEAR? DATE:
7.WHEN DID PATIENT FIRST CONSULT YOU FOR THIS CONDITION? DATE:
8. HAS PATIENT EVER HAD SAME OR SIMILAR CONDITION?
YES
NO
IF YES, state when and describe:
9. IS CONDITION SOLELY A RESULT OF THIS AUTOMOBILE ACCIDENT?
YES
NO
IF "NO", explain:
10. IS CONDITION DUE TO INJURY ARISING OUT OF PATIENT’S EMPLOYMENT?
YES
NO
11. WILL INJURY RESULT IN SIGNIFICANT DISFIGUREMENT OR PERMANENT DISABILITY?
YES |
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NO |
IF "YES", describe: |
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NOT DETERMINABLE AT THIS TIME
12. PATIENT WAS DISABLED (UNABLE TO WORK) |
13. IF STILL DISABLED THE PATIENT SHOULD BE |
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ABLE TO RETURN TO WORK ON: |
FROM: |
THROUGH: |
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(DATE)
CONTINUE ON PAGE 2
NYS FORM
Page 1 of 3
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
PAGE 2
14.WILL THE PATIENT REQUIRE REHABILITATION AND/OR OCCUPATIONAL THERAPY AS A RESULT OF THE INJURIES SUSTAINED IN THIS ACCIDENT?
YES |
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NO |
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IF YES, describe your recommendation below: |
15. REPORT OF SERVICES RENDERED
DATE OF PLACE OF SERVICE SERVICE INCLUDING ZIP CODE
DESCRIPTION OF TREATMENT OR HEALTH SERVICE RENDERED
FEE SCHEDULE TREATMENT CODE
CHARGES
TOTAL CHARGES TO DATE$
16. IF TREATING PROVIDER IS DIFFERENT THAN BILLING PROVIDER COMPLETE THE FOLLOWING:
TREATING PROVIDER'S |
TITLE |
LICENSE OR |
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BUSINESS RELATIONSHIP |
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NAME |
CERTIFICATION NO. |
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CHECK APPLICABLE BOX |
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EMPLOYEE |
INDEPENDENT |
OTHER (SPECIFY) |
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CONTRACTOR |
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17.IF THE PROVIDER OF SERVICE IS A PROFESSIONAL SERVICE CORPORATION OR DOING BUSINESS UNDER AN ASSUMED NAME (DBA), LIST THE OWNER AND PROFESSIONAL LICENSING CREDENTIALS OF ALL OWNERS (Provide an additional attachment if necessary).
18. IS PATIENT STILL UNDER YOUR CARE FOR THIS CONDITION? |
YES |
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NO |
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19. ESTIMATED DURATION OF FUTURE TREATMENT
PATIENT: Your health provider may agree to accept payment for health services performed directly from your insurer (Authorization to Pay Benefits) so that you are not required to make payment to the health provider at the time of service. Such agreement is optional on the part of the health provider and must be signed by both patient and health provider. You may use the optional authorization language provided below, by checking off the designated spot in item 20 of this form.
20.(IF YOU HAVE CHOSEN TO AUTHORIZE THE DIRECT PAYMENT OF BENEFITS BY CHECKING THIS OPTION, YOU MAY NOT ALSO ENTER INTO AN ASSIGNMENT OF BENEFITS CONTAINED IN #21)
AUTHORIZATION TO PAY BENEFITS:
I AUTHORIZE PAYMENT OF HEALTH BENEFITS TO THE UNDERSIGNED HEALTH CARE PROVIDER OR SUPPLIER OF SERVICES DESCRIBED BELOW. I RETAIN ALL RIGHTS, PRIVILEGES AND REMEDIES TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE
PRINT NAME |
SIGNED |
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PATIENT |
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PATIENT |
DATE |
CONTINUE ON PAGE 3
NYS FORM
Page 2 of 3
VERIFICATION OF TREATMENT BY ATTENDING PHYSICIAN OR OTHER PROVIDER OF HEALTH SERVICE
PAGE 3
PATIENT: Your health provider may agree to have you assign your right to
21.(IF YOU HAVE CHOSEN TO ASSIGN YOUR BENEFITS TO THE HEALTH PROVIDER BY CHECKING THIS OPTION, YOU MAY NOT ALSO ENTER INTO AN AUTHORIZATION TO PAY BENEFITS CONTAINED IN ITEM #20 ABOVE)
ASSIGNMENT OF
I HEREBY ASSIGN TO THE HEALTH CARE PROVIDER INDICATED BELOW ALL RIGHTS, PRIVILEGES AND REMEDIES TO PAYMENT FOR HEALTH CARE SERVICES PROVIDED BY THE ASSIGNEE TO WHICH I AM ENTITLED UNDER ARTICLE 51 (THE
PRINT NAME |
SIGNED |
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PATIENT (Assignor) |
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PATIENT |
DATE |
PRINT NAME |
SIGNED |
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PROVIDER OF HEALTH CARE SERVICE (Assignee) |
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PROVIDER OF HEALTH CARE SERVICE |
DATE |
HAS AN ORIGINAL AUTHORIZATION OR ASSIGNMENT PREVIOUSLY BEEN EXECUTED?
YES
NO
IS THE ORIGINAL SIGNATURE OF THE PARTIES ON FILE?
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.
DATE
PROVIDER'S SIGNATURE
IRS/TIN IDENTIFICATION NO.
WCB RATING CODE IF NONE, SPECIALTY
*LANGUAGE TO BE FILLED IN BY INSURER OR
Page 3 of 3
NEW YORK MOTOR VEHICLE
ASSIGNMENT OF BENEFITS FORM
(FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/02)
I, |
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, ("Assingor") hereby assign to |
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, ("Assignee") |
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(Print patient's name) |
(Print hospital or health care provider name) |
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all rights privileges and remedies to payment for health care services provided by assignee to which I am entitled under Article 51 (the
The Assignee hereby certifies that they have not received any payment from or on behalf of the Assignor and shall not pursue payment directly from the Assignor for services provided by said Assignee for injuries sustained
due to the motor vehicle accident which occurred on |
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, not withstanding any other agreement |
(Print accident date)
to the contrary.
This agreement may be revoked by the assignee when benefits are not payable based upon the assignor’s lack of coverage and/or violation of a policy condition due to the actions or conduct of the assignor.
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 of Patient) |
(Signature of Patient) |
(Date of signature)
(Address of Patient)
(Print name of Provider) |
(Signature of Provider) |
(Date of signature)
(Address of Provider)
NYS FORM