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