New York Motor Vehicle No-Fault Insurance Law Arbitration Request Form If you wish to arbitrate your claim, please complete (print or type) all applicable sections of this form. Optional No-Fault Arbitration is final and binding except for the limited grounds for review set forth in the law and regulations. Upon receipt of this request, the American Arbitration Association will attempt to resolve the dispute by conciliation pursuant to Insurance Department Regulation 11NYCRR 65-4.2 (b) (2) (iii). If the dispute cannot be resolved by conciliation, your case will be forwarded for arbitration. For additional information please visit our website at: www.adr.org, and click on “New York No-Fault” in the right hand column. Pursuant to Insurance Department Regulation 11NYCRR 65 – 4.2 (b) (3) (i), the applicant shall submit all supporting documentation with their request for arbitration. Submitted documentation must contain a table of contents and exhibits. The applicant must also simultaneously submit all documents to the insurer. Following this original submission of documents, any other documents submitted by the applicant other than bills or claims for ongoing benefits will be marked “LATE SUBMISSION” and will be admitted into the record at the sole discretion of the arbitrator. Pursuant to Insurance Department Regulation 11NYCRR 65 – 4.5 (t) (1), the arbitrator may impose all administrative costs of arbitration to the applicant or apportion the administrative costs of arbitration between the parties if the arbitrator concludes that the applicant’s arbitration request was frivolous, was without factual or legal merit or was filed for the purpose of harassing the respondent. Part 1. Parties in Dispute Applicant for benefits Last name First name Address First name Were benefits assigned to provider? ___ Yes ___ No Date of accident Address Injured person Last name Policyholder Last name Policy number First name Address Insurer or self-insurer Insurer’s claims office address Insurer’s representative Telephone number * If bringing arbitration against MVAIC, please provide claim beginning with prefix “P”, if available. Insurer claim or file number MVAIC claim number * Did the accident occur in New York State? Yes___ No___ If no, is the injured person or a member of their household a New York State Automobile Policy Holder? Yes___ No___ The injured person named above was the ( ) Driver ( ) Passenger ( ) Pedestrian ( ) Bicyclist ( ) Other (Please explain) _______________________________________________________________________________________________________ _______________________________________________________________________________________________________ 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: _______________________________________________________________________________________________________ AAA Form AR [Effective June 2004] American LegalNet, Inc. www.FormsWorkFlow.com New York Motor Vehicle No-Fault Insurance Law Arbitration Request Form, Page 2 Part 2. Requests for Special Handling Written Submissions Arbitration: (11 NYCRR 65-4.5 (a) provides for arbitration on the basis of written submissions, at the discretion of the arbitrator, if the amount in dispute is less than $2,000.) Are you interested in having this case decided by the arbitrator entirely on the written submissions, without an in-person hearing? Yes___ No___ Are you interested in having a telephone hearing of this case, instead of an in-person hearing? Yes___ No___ Priority Arbitration (90-day): (11 NYCRR 65-4.5 (i) (2) provides for Priority Arbitration in cases where the request for arbitration is made within 90 days after either a denial of claim was received or the claim became overdue, for EACH claim in dispute. A file that qualifies for Priority Arbitration is scheduled within 45 days from the date of transmittal from the conciliation center.) Are you filing within 90 days after each claim in dispute was denied or became overdue? Yes___ No___ Special Expedited Arbitration (Late Notice): (11NYCRR 65-4.5 (b) provides for Special Expedited Arbitration proceedings for cases that were denied based on failure to submit notice of claim within 30 days after the accident. To qualify you must request Special Expedited Arbitration within 30 days after the mailing of the denial.) Was the denial of claim based on late notice to the carrier? Yes___ No___ If yes, are you requesting Special Expedited Arbitration? Yes___ No___ Part 3. Claim(s) in Dispute (Please place a check mark next to space where appropriate.) _____ Medical (If health benefit claims are in dispute, please attach all bills in question (mark as “Exhibit A”), supporting documentation - reports, findings, narratives, etc. (mark as “Exhibit B”), assignment of benefits, if applicable (mark as “Exhibit C”). If more space is needed, please use AAA Form AR-Sup, on page 4 of this Form AR.) Doctor, hospital or other health provider Amount of each bill Totals: Amount paid $0.00 Unpaid or disputed balance $0.00 Are additional bills on AAA Form AR-Sup? $0.00 Yes _____ Dates of service Date bill mailed Was verification requested No Yes Date supplied Any request in which total column is not completed will be returned. No ____ _____ Other Necessary Expense(s) (Attach bills in dispute as separate exhibit with supporting documentation - If more space is needed, please use AAA Form AR-Sup, on page 4 of this Form AR.) Type of expense claimed Amount claimed Totals: Are additional expenses on AAA Form AR-Sup? Amount in dispute $0.00 Yes ____ $0.00 Date incurred Date mailed Any request in which total column is not completed will be returned. No ____ AAA Form AR [Effective June 2004] American LegalNet, Inc. www.FormsWorkFlow.com New York Motor Vehicle No-Fault Insurance Law Arbitration Request Form, Page 3 _____ Interest Benefit paid late Amount of bill Date mailed to insurer Was verification requested? No Yes Date supplied _____ Death Benefit Date death certificate mailed to insurer: __________ _____ Loss of Earnings Date paid by insurer Period in dispute: from: _________ to: __________ Gross earnings per month: $ _________ Amount claimed: $ __________ Date claim was made: __________ _____ Attorney’s Fee Does this arbitration request include all issues known by the applicant/attorney to be in dispute with the insurer? Yes___ No___ If no, attach explanation. Was a denial issued? Yes___ No___ If yes, attach a copy. If no, please explain on what basis claim was not paid: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ Reason you believe the denied or overdue benefits should be paid: ______________________________________________________________________________________________________ ______________________________________________________________________________________________________ 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. The undersigned affirms and certifies as true under the penalty of perjury that this filing is being made in good faith and that upon information, belief and reasonable inquiry the documents being submitted herewith are not fraudulent and that exact copies of all documents provided herewith have been mailed to the insurer against whom the arbitration is being requested. Unless disclosed with this submission, the disputed amounts remain unpaid to the applicant by any payor and there has been no other filing of an arbitration request or lawsuit to resolve the disputed matters contained in this submission. Arbitration requested by Last name Name of law firm, if any First name Telephone number Address Signature Are you an attorney? Email Date Fax number ___ Yes ___ No How to file: 1. Mail the completed form and all requested attachments in duplicate together with a $40.00 filing fee payable to the American Arbitration Association to: American Arbitration Association, New York Insurance Case Management Center, 65 Broadway, New York, NY 10006. 2. Mail a duplicate copy of this entire filing including all attachments to the insurer against whom you are requesting arbitration and retain a copy for your records. 3. Make sure to include a table of contents and exhibits. AAA Form AR [Effective June 2004] American LegalNet, Inc. www.FormsWorkFlow.com New York Motor Vehicle No-Fault Insurance Law Arbitration Request Form, Page 4 AAA Form AR-Sup - Supplemental Information for Part 3 Include this page with your filing only if applicable. Medical: Please continue from Part 3, Page 2. 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 No Yes Date supplied Totals: $0.00 $0.00 $0.00 Any request in which total column is not completed will be returned. Other Necessary Expenses: Please continue from Part 3, Page 2. Type of expense claimed Totals: AAA Form AR Sup [Effective June 2004] Amount claimed $0.00 Amount in dispute $0.00 Date incurred Date mailed Any request in which total column is not completed will be returned. American LegalNet, Inc. www.FormsWorkFlow.com