NY Motor Vehicle No-Fault Inurance Law Cover Letter

1 DATEDEAR APPLICANT: FORM NF-1A (Rev 6/2013)Page 1 of 2a$2,000deathbenefit,payabletotheestateo facoveredperson,inadditiontothe$50,000co verageforeconomic loss described above. Additionalbenefitsmaybeowedtoyouiftheabo vepolicyhasbeenendorsedtoincludeOptional BasicEconomicLosscoverage and/or Additional Personal Injury Protection ,amountsrecoveredorrecoverableonaccounto ftheaccidentfromWorkers'Compensation,New YorkStateDisability,andcertainwagecontin uationplanswillreduceyourNo-Fault benefits. Therefore, if you are entitled to any of these benefits you should make your claim for them ,youmaybeentitledtoanadditional$25, ,butinnoeventlaterthan90daysafteryour$50 ,000ofBasicEconomicLosscoverageunderthis policy is :TheNo-FaultLawprovidesthatifyouareinjur edonabusoraschoolbusinNewYorkState,No-Fa ultbenefitsmustbepaidbyyourautoinsureror ifyouhavenoauto, ,youmayfileaNo-Faultclaimwiththeinsurero fthebusorschoolbusifyou are the operator, owner or employee of the owner of the bus AND ADDRESS OF ,TELEPHONETHENEWYORKSTATEDISABILITYBENEF ITSBUREAUAT(800) loss.

2 Briefly summarized, basic economic loss consists of up to $50,000 per person in benefits for the following: allnecessarydoctorandhospitalbillsandoth erhealthserviceexpenses,payableinaccorda ncewithfeeschedules established or adopted by the New York State Department of Financial Services; 80%oflostearningsuptoamaximummonthlypaym entof$2,000foruptothreeyearsfollowingthe dateoftheaccident; upto$25perdayforaperiodofoneyearfromthed ateoftheaccidentforotherreasonableandnec essaryexpensestheinjuredpersonmayhaveinc urredbecauseofaninjuryresultingfromtheac cident,suchasthecostof hiring a housekeeper or necessary transportation expenses to and from a health service provider; and NEW YORK Motor Vehicle No-Fault INSURANCE LAWCOVER LETTERNAME, ADDRESS AND PHONE NUMBER OF INSURER, SELF-INSURER OR REPRESENTATIVE*NAME, ADDRESS AND PHONE NUMBER OF CLAIM REPRESENTATIVE*POLICYHOLDERPOLICY NUMBERDATE OF ACCIDENTCLAIM NUMBERVery truly yours, *LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.

3 NYS FORM NF-1A (Rev 6/2013)Page 2 of 2 PLEASE ANSWER ALL QUESTIONS ON THE APPLICATION FORM AND SIGN BOTHAUTHORIZATIONS SO THAT WE MAY GIVE PROMPT ATTENTION TO YOUR CLAIMCOVER Letter -- PAGE TWOT oenableustodetermineifyouareentitledtoan yNo-Faultbenefits,pleasecompleteandimmed iatelyreturntheenclosedAPPLICATIONFORMOT ORVEHICLENO-FAULTBENEFITS(NYSFORMNF-2) , , , , at the phone number provided at the top of page NOTE THAT THE TIME ALLOWED FOR PROVIDING NOTICE AND PROOF OF CLAIM TO YOUR INSURER HAS BEEN REDUCED. FAILURE TO RETURN A COMPLETED APPLICATION FOR Motor Vehicle No-Fault BENEFITS FORM (NF-2) TO YOUR INSURER TIMELY CAN RESULT IN LOSS OF ALL BENEFITS. FAILURE TO SUBMIT BILLS FOR HEALTH CARE SERVICES WITHIN 45 DAYS OF TREATMENT OR MAKE CLAIM FOR LOST EARNINGS OR OTHER REASONABLE AND NECESSARY EXPENSES WITHIN 90 DAYS OF OCCURRENCE CAN RESULT IN THOSE BENEFITS BEING DENIED. If your insurer denies coverage for failure to make a timely submission you can provide them with a written reply stating why you could not reasonably meet the time frames and your insurer must consider ,ORCONCEALSFORTHEPURPOSEOFMISLEADING,INF ORMATIONCONCERNINGANYFACTMATERIALTHERETO ,ANDANYPERSONWHO,INCONNECTIONWITHSUCHAPP LICATIONORCLAIM,KNOWINGLYMAKESORKNOWINGL YASSISTS,ABETS,SOLICITSORCONSPIRESWITHAN OTHERTOMAKEAFALSEREPORTOFTHETHEFT,DESTRU CTION,DAMAGEORCONVERSIONOFANYMOTORVEHICL ETOALAWENFORCEMENTAGENCY,THEDEPARTMENTOF MOTORVEHICLESORANINSURANCECOMPANY,COMMIT SAFRAUDULENTINSURANCEACT,WHICHISACRIME,A NDSHALLALSOBESUBJECTTOACIVILPENALTYNOTTO EXCEEDFIVETHOUSANDDOLLARSANDTHEVALUE OF THE SUBJECT Motor Vehicle OR STATED CLAIM FOR EACH REMINDERS DATEDEAR APPLICANT.

4 FORM NF-1B (Rev 6/2013)Page 1 of 2 NEW YORK Motor Vehicle No-Fault INSURANCE LAWCOVER LETTERNAME, ADDRESS AND PHONE NUMBER OF INSURER, SELF-INSURER OR REPRESENTATIVE*NAME, ADDRESS AND PHONE NUMBER OF CLAIM REPRESENTATIVE*NAME AND ADDRESS OF APPLICANTPOLICYHOLDERPOLICY NUMBERDATE OF ,TELEPHONETHENEWYORKSTATEDISABILITYBENEF ITSBUREAUAT(800)353-3092 CLAIM loss. Briefly summarized, basic economic loss consists of up to $50,000 per person in benefits for the following: allnecessarydoctorandhospitalbillsandoth erhealthserviceexpenses,payableinaccorda ncewithfeeschedules established or adopted by the New York State Department of Financial Services; 80%oflostearningsuptoamaximummonthlypaym entof$2,000foruptothreeyearsfollowingthe dateoftheaccident; upto$25perdayforaperiodofoneyearfromthed ateoftheaccidentforotherreasonableandnec essaryexpensestheinjuredpersonmayhaveinc urredbecauseofaninjuryresultingfromtheac cident,suchasthecostof hiring a housekeeper or necessary transportation expenses to and from a health service provider; and a$2,000deathbenefit,payabletotheestateof acoveredperson,inadditiontothe$50,000cov erageforeconomic loss described above.

5 Additionalbenefitsmaybeowedtoyouiftheabo vepolicyhasbeenendorsedtoincludeOptional BasicEconomicLosscoverage and/or Additional Personal Injury Protection ,amountsrecoveredorrecoverableonaccounto ftheaccidentfromWorkers'Compensation,New YorkStateDisability,andcertainwagecontin uationplanswillreduceyourNo-Fault benefits. Therefore, if you are entitled to any of these benefits you should make your claim for them ,youmaybeentitledtoanadditional$25, ,butinnoeventlaterthan90daysafteryour$50 ,000ofBasicEconomicLosscoverageunderthis policy is :TheNo-FaultLawprovidesthatifyouareinjur edonabusoraschoolbusinNewYorkState,No-Fa ultbenefitsmustbepaidbyyourautoinsureror ifyouhavenoauto, are the operator, owner or employee of the owner of the bus truly yours, *LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER. NYS FORM NF-1B (Rev 6/2013)Page 2 of , , , , number provided at the top of page ANSWER ALL QUESTIONS ON THE APPLICATION FORM AND SIGN BOTHAUTHORIZATIONS SO THAT WE MAY GIVE PROMPT ATTENTION TO YOUR CLAIMT oenableustodetermineifyouareentitledtoan yNo-Faultbenefits,pleasecompleteandimmed iatelyreturntheenclosedAPPLICATIONFORMOT ORVEHICLENO-FAULTBENEFITS(NYSFORMNF-2)

6 ,ORCONCEALSFORTHEPURPOSEOFMISLEADING,INF ORMATIONCONCERNINGANYFACTMATERIALTHERETO ,ANDANYPERSONWHO,INCONNECTIONWITHSUCHAPP LICATIONORCLAIM,KNOWINGLYMAKESORKNOWINGL YASSISTS,ABETS,SOLICITSORCONSPIRESWITHAN OTHERTOMAKEAFALSEREPORTOFTHETHEFT,DESTRU CTION,DAMAGEORCONVERSIONOFANYMOTORVEHICL ETOALAWENFORCEMENTAGENCY,THEDEPARTMENTOF MOTORVEHICLESORANINSURANCECOMPANY,COMMIT SAFRAUDULENTINSURANCEACT,WHICHISACRIME,A NDSHALLALSOBESUBJECTTOACIVILPENALTYNOTTO EXCEEDFIVETHOUSANDDOLLARSANDTHEVALUE OF THE SUBJECT Motor Vehicle OR STATED CLAIM FOR EACH REMINDERSCOVER Letter -- PAGE TWODATEIMPORTANT:1. YOUR NAME2. PHONE YOUR ADDRESS 4. DATE OF BIRTH5. SOCIAL SECURITY NO. (NO., STREET, CITY OR TOWN AND ZIP CODE)6. DATE AND TIME OF ACCIDENT7. PLACE OF ACCIDENT (STREET), CITY OR TOWN AND STATE BRIEF DESCRIPTION OF ACCIDENT9. DESCRIBE YOUR INJURY10. IDENTITY OF Vehicle YOU OCCUPIED OR OPERATED AT THE TIME OF THE ACCIDENT:THIS Vehicle WAS:A BUS OR SCHOOL BUS,A TRUCK,AN AUTOMOBILE,OR A MOTORCYCLEYESNO11.

7 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 ?NYS FORM NF-2 (Rev 1/2004)Page 1 of 3 CONTINUATION ON NEXT PAGENAME AND ADDRESS OF APPLICANT*OWNER'S NAMEMAKEYEARTO 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. 1. TO BE ELIGIBLE FOR BENEFITS YOU MUST COMPLETE AND SIGN THIS YOU MUST SIGN ANY ATTACHED AUTHORIZATION(S). 3. RETURN PROMPTLY WITH COPIES OF ANY BILLS YOU HAVE RECEIVED TO DATE. POLICYHOLDERPOLICY NUMBERDATE OF ACCIDENTCLAIM NUMBERNEW YORK Motor Vehicle No-Fault INSURANCE LAWAPPLICATION FOR Motor Vehicle No-Fault BENEFITSNAME AND ADDRESS OF INSURER *NAME, ADDRESS, AND PHONE NUMBER OF INSURER S CLAIMS REPRESENTATIVE*12. WERE YOU TREATED BY A DOCTOR(S) OR OTHER PERSON(S) FURNISHING HEALTH SERVICES?

8 YESNOIF 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 YESNO EMPLOYMENT?$YESNO17. DID YOU LOSE TIME DATE ABSENCE FROM HAVE YOU RETURNED TO FROM WORK?WORK BEGAN:WORK?YESNOYESNOIF 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? YESNO20. 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 OCCUPATIONFROMTO EMPLOYER AND ADDRESS OCCUPATIONFROMTO EMPLOYER AND ADDRESS OCCUPATIONFROMTO 21.

9 AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES? YESNO 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:YESNONEW YORK STATE DISABILITY?WORKERS' COMPENSATION?NYS FORM NF-2 (Rev 1/2004)Page 2 of 3 APPLICATION FOR Motor Vehicle No-Fault BENEFITS - - PAGE TWOCONTINUATION ON NEXT PAGETHE 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 THENO-FAULT LAW.(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 THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAYHAVE REGARDING MY CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORYOBTAINED, X-RAYS AND PHYSICAL FINDINGS, DIAGNOSIS AND PROGNOSIS.

10 YOU ARE AUTHORIZED TO PROVIDETHIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE Motor Vehicle INSURANCEREPARATIONS ACT ( No-Fault LAW).NAME (PRINT OR TYPE)SIGNATUREDATESIGNATUREDATEDO NOT DETACHAUTHORIZATION FOR RELEASE OF HEALTH SERVICE OR TREATMENT INFORMATIONAUTHORIZATION FOR RELEASE OF WORK AND OTHER LOSS INFORMATIONTHIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAYHAVE REGARDING MY WAGES, SALARY OR OTHER LOSS WHILE EMPLOYED BY YOU. YOUR ARE AUTHORIZED TOPROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE Motor VEHICLEINSURANCE REPARATIONS ACT ( No-Fault LAW).NAME (PRINT OR TYPE)SOCIAL SECURITY NOT DETACHTHIS FORM IS SUBSCRIBED AND AFFIRMED BY THEAPPLICANT AS TRUE UNDER THE PENALTIES OF PERJURYANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHERPERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANYCOMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION,OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIALTHERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLYMAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSEREPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY Motor Vehicle TO A LAWENFORCEMENT AGENCY, THE DEPARTMENT OF Motor VEHICLES OR AN INSURANCE COMPANY,COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME.