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NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM (FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/02) Claim Number: I, (Assignor”) hereby assign to, (“Assignee) (Print patient's
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If you were injured as a result of a medical emergency in which you requested medical services by the assigned/assignee physician/hospital or health care provider, the Assignee has received a payment for medical expenses and related costs. If you are a policyholder (employee, employer, or policyholder who is the primary obliged of the insurance policy) who was injured as a result of a medical emergency in which you requested medical services by the assigned/assignee physician or hospital or health care provider, then you have not received any payment from the Assignee for medical expenses, related medical costs and related costs, and you should contact the Assignee directly. You must provide the information here, to the appropriate office listed below, in order to receive payment for medical expenses, related medical costs, and related costs, provided under the No-Fault Statute. If you are not satisfied with the services provided for you under the No-Fault Statute or are unable to make a claim through the Claims Office of our insurance agent/service provider, you are only entitled to payment from the applicable No-Fault Assessor; for example, if you are an employee or a parent/guardian of a child, and not a policyholder, the Assignee is the No-Fault Assessor. Payment of the claimed amount shall be made to the Assignor by the Assignee within six (6) weeks from our notification of receipt of the documentation below. If any of the required documents are not supplied with the No-Fault Claim Form, your insurance agent/service provider will need to be contacted to submit the missing documentation for reimbursement. This is how to submit the necessary paperwork needed to have payment made: Insurance Claim Form. Insurance Claim Form Instructions for Filing Insurance Claim Form The No-Fault Assessor determines what your Medical Expense Benefits are by applying certain criteria to the facts as stated on the Insurance Claim Form and the documentation provided to us. You may have other medical expenses that are not covered by the No-Fault Policy, and will not be covered by your No-Fault insurance policy (see below for more details).

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