Get NYS NF-10 2012
should send to the injured person a copy of all prescribed claim forms and documents submitted by or on behalf of the injured person. NAME, ADDRESS AND NAIC NUMBER OF INSURER OR NAME AND ADDRESS OF SELF-INSURER A. POLICYHOLDER E. CLAIM NUMBER B. POLICY NUMBER For American Arbitration Association use C. DATE OF ACCIDENT D. INJURED PERSON F. APPLICANT FOR BENEFITS (Name and address) G. AS ASSIGNEE YES NO TO APPLICANT: SEE REVERSE SIDE IF YOU WISH TO CONTEST THIS DENIAL YOU ARE ADVISED THA.
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