New York No-Fault Arbitration Form

Part 1. Parties in Dispute
Applicant for benefits
Full Name

First NameLast Name
Address
Were benefits assigned to provider?
Injured person
Full Name

First NameLast Name
Address
Date of Accident

MonthDayYear
Policyholder
Full Name

First NameLast Name
Address
Policy Number
Insurer or self-insurer
Insurer's claims office address
Insurer's Representative
Telephone Number

Area CodePhone Number
Claim Number
Did The accident occur in New York State?
If no, is the injured person or member of their household a New York State Automobile Policy Holder?
The injured person named above was the
Detail from above
Every attempt should be made to resolve this claim with the insurer prior to filing for arbitration.
When was the insurer last contacted?
Name and title of person contacted:
Part 2. Requests for Special Handling
Are you interested in having this case decided by the arbitrator entirely on the written submissions, without an in-person hearing?
Are you interested in having a telephone hearing of this case, instead of an in-person hearing?
Part 3. Claim(s) in Dispute
Medical (if health benefit claims are in dispute, please attach all bills in question, assignment of benefits and denial of claim form(s) (if applicable)

Rows	Doctor, hospital or Other health Provider	Amount of each bill	Amount paid	Unpaid or disputed balance	Dates of service	Date bill mailed	Was verification requested? (yes or no)	Date Supplied
1.)
2.)
3.)
4.)
5.)
Totals

Part 1. Parties in Dispute