Fillable COVER LETTER POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT (Plymouth Rock Assurance)

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COVER LETTER POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT (Plymouth Rock Assurance)

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DATE
DEAR APPLICANT:
a.
b.
c.
d.
NYS FORM NF-1A (Rev 6/2013)
Page 1 of 2
a $2,000 death benefit, payable to the estate of a covered person, in addition to the $50,000 coverage for
economic loss described above.
Additional benefits may be owed to you if the above policy has been endorsed to include Optional Basic Economic Loss
coverage and/or Additional Personal Injury Protection coverage.
In determining the benefits payable to you under the No-Fault Law, amounts recovered or recoverable on account of the
accident from Workers' Compensation, New York State Disability, and certain wage continuation plans will reduce your No-
Fault benefits. Therefore, if you are entitled to any of these benefits you should make your claim for them promptly.
If you are a named insured or relative under a Mandatory Personal Injury Protection policy which includes OBEL coverage,
you may be entitled to an additional $25,000 of Basic Economic Loss coverage. You should make your claim to that motor
vehicle insurer promptly, but in no event later than 90 days after your $50,000 of Basic Economic Loss coverage under this
policy is exhausted.
NOTE: The No-Fault Law provides that if you are injured on a bus or a school bus in New York State, No-Fault benefits must
be paid by your auto insurer or if you have no auto, the auto insurer of a relative with whom you reside. The law further
provides that you should only file a No-Fault claim with the insurer of the bus or school bus if there is no such auto policy in
your household. If the above rule does not apply, you may file a No-Fault claim with the insurer of the bus or school bus if
you are the operator, owner or employee of the owner of the bus company.
COMPLETE THE ATTACHED DB-450 FORM
IMMEDIATELY IF YOU ARE ENTITLED TO NEW
YORK STATE DISABILITY BENEFITS AND MAIL OR
GIVE IT TO YOUR EMPLOYER. TO FIND OUT IF
YOU ARE ELIGIBLE, TELEPHONE THE NEW YORK
STATE DISABILITY BENEFITS BUREAU AT (800)
353-
3092
This will acknowledge receipt of notice that you may have sustained injuries in the above captioned accident. The New York
No-Fault Law provides for the payment of benefits to victims of motor vehicle accidents to reimburse them for their basic
economic loss. Briefly summarized, basic economic loss consists of up to $50,000 per person in benefits for the following:
all necessary doctor and hospital bills and other health service expenses, payable in accordance with fee
schedules established or adopted by the New York State Department of Financial Services;
80% of lost earnings up to a maximum monthly payment of $2,000 for up to three years following the date of the
accident;
up to $25 per day for a period of one year from the date of the accident for other reasonable and necessary
expenses the injured person may have incurred because of an injury resulting from the accident, such as the cost
of hiring a housekeeper or necessary transportation expenses to and from a health service provider; and
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
COVER LETTER
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NAME, ADDRESS AND PHONE NUMBER
OF INSURER, SELF-INSURER OR
REPRESENTATIVE*
NAME, ADDRESS AND PHONE
NUMBER OF CLAIM
REPRESENTATIVE*
NAME AND ADDRESS OF
APPLICANT
Very truly yours,
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-1A (Rev 6/2013)
Page 2 of 2
PLEASE ANSWER ALL QUESTIONS ON THE APPLICATION FORM AND SIGN BOTH
AUTHORIZATIONS SO THAT WE MAY GIVE PROMPT ATTENTION TO YOUR CLAIM
COVER LETTER -- PAGE TWO
To enable us to determine if you are entitled to any No-Fault benefits, please complete and immediately return the enclosed
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS (NYS FORM NF-2) along with copies of any bills you have
received to date. This application must be sent to us within 30 days of the accident date if your original notice to us was not in
writing.
You are entitled to receive health service benefits without any time limit if it is possible to determine during the first
year after the accident that further health services may be required after the first year. As you receive additional
medical bills or any other bills you believe to be covered, send them to us immediately. In order to be considered
for payment, all bills for health care services must be submitted within 45 days of treatment. If it is not possible for
you or your health care provider to submit these bills within that time period, submit a written explanation of the
reason for the delay. Claims for lost earnings and other reasonable and necessary expenses must be submitted
within 90 days. We will reimburse you as soon as we are able to verify that they are covered expenses under No-
Fault. Please identify all communications with us with the claim number shown above. Should you have any
questions concerning your claim, we will be most happy to assist you. Please feel free to call the claim
representative at the phone number provided at the top of page one.
PLEASE 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 it.
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.
IMPORTANT REMINDERS
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COVER LETTER POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT (Plymouth Rock Assurance)

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Completed 3 August 2021

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