DATE
DEAR EMPLOYER:
The above named person has applied for benefits under the NEW YORK COMPREHENSIVE MOTOR VEHICLE
INSURANCE REPARATIONS ACT (NO-FAULT LAW) as a result of injuries sustained in a motor vehicle accident on the
date indicated. We understand this person is your employee or former employee. To assist us in determining benefits
that may be due the applicant, please provide us with the answer to the following questions.
PLEASE COMPLETE AND SUBMIT THIS FORM TO OUR CLAIMS REPRESENTATIVE AS SOON
AS POSSIBLE. PLEASE NOTE COMPLETED FORM MUST BE SUBMITTED TO INSURER NO
LATER THAN 90 DAYS AFTER WORK LOSS WAS FIRST INCURRED
Thank you for your cooperation.
1. EMPLOYEE'S OCCUPATION:
2. DATES OF EMPLOYMENT : FROM THROUGH
3. GROSS EARNINGS DURING 52 WEEK PERIOD PRIOR TO ACCIDENT: $
WAGE OR SALARY AS OF DATE OF ACCIDENT:
$$$
NUMBER OF HOURS NORMALLY WORKED PER DAY
NUMBER OF DAYS NORMALLY WORKED PER WEEK
4. DATES ABSENT FOLLOWING ACCIDENT:
FIRST DAY ABSENT FROM WORK
DATE RETURNED TO WORK
5. HAS EMPLOYEE RECEIVED, IS EMPLOYEE RECEIVING OR IS EMPLOYEE ENTITLED TO RECEIVE
BENEFITS UNDER ANY WORKERS' COMPENSATION LAW AS A RESULT OF THIS ACCIDENT?
YES NO
WORKER'S COMPENSATION INSURER
ADDRESS
POLICY NUMBER
NYS FORM NF-6 (Rev 1/2004)
Page 1 of 2
UNDETERMINED
NAME AND ADDRESS OF EMPLOYER*
EMPLOYEE'S NAME, ADDRESS AND SOCIAL
SECURITY NO.
CLAIM REPRESENTATIVE
HOURLY WEEKLY MONTHLY
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
EMPLOYER'S WAGE VERIFICATION REPORT
NAME AND ADDRESS OF INSURER OR SELF-
INSURER*
NAME, ADDRESS, AND PHONE NUMBER OF
INSURER’S CLAIMS REPRESENTATIVE*
6. HAS EMPLOYEE RECEIVED, IS EMPLOYEE RECEIVING OR IS EMPLOYEE ENTITLED TO RECEIVE
NEW YORK STATE DISABILITY BENEFITS AS A RESULT OF THIS ACCIDENT?
YES NO
IS THE EMPLOYEE REQUIRED TO PAY FOR DBL COVERAGE THROUGH PAYROLL DEDUCTION?
YES NO
NYS DISABILITY INSURER
ADDRESS
POLICY NUMBER
7. WAS OR WILL EMPLOYEE BE PAID BY EMPLOYER FOR THIS ABSENCE FROM WORK?
YES NO
IF ANSWER TO QUESTION 7 IS "YES" PLEASE ANSWER QUESTIONS 8, 9, 10 and 11.
8. HOW MUCH WAS OR WILL EMPLOYEE BE PAID $ $
9. WILL THE EMPLOYEE BE REQUIRED TO REIMBURSE YOU ANY OF THE ABOVE AMOUNT?
YES NO
10. WILL THE EMPLOYEE LOSE ACCUMULATED LEAVE CREDITS AS A RESULT OF THE
FOREGOING PAYMENT?
YES NO
11. WILL THE EMPLOYEE'S ELIGIBILITY FOR FUTURE WAGE BENEFITS BE AFFECTED BY PAYMENTS
INDICATED IN QUESTION 8 ABOVE?
YES NO
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-6 (Rev 1/2004)
Page 2 of 2
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.
PRINT NAME
SIGNATURE
TITLE
FEDERAL EMPLOYER I.D. NO.
PHONE NO.
DATE
EMPLOYER'S WAGE VERIFICATION REPORT -- PAGE TWO
UNDETERMINED
WEEKLY MONTHLY
