Preview
INDEX NO. 85102/2024
NYSCEF DOC. NO. 6 RECEIVED NYSCEF: 05/03/2024
GULLO & ASSOCIATES, LLC.
ATTORNEYS AT LAW
1265 Richmond Avenue
Staten Island, New York 10314
Tel: (718) 238-9555
Fax: (718) 238-9552
American Arbitration Association
120 Broadway - 11" Floor
New York, New York 10271
Attention: Arbitration Team#6
Re: AAA Case No.: 41-23-1291-5441
Applicant: Lasalle Ambulance Inc
Applicant Representative: Super Associates PC
Respondent: New York Central Mutual Fire Insurance Company
Respondent Representative: Gullo & Associates, LLC
Injured Party(ies): Randyshnel L Stevens
Date of Accident: 11/30/22 Dates of Service: 11/30/22
Amount in Dispute: 2,510.00 Claim #: 2022-506197-1
Our File No.: NYCM.NF-31225
The following bill must be dismissed as premature
No-Fault benefits are overdue if not paid within 30 calendar days after the insurer
receives proof of claim, which shall include verification of all of the relevant information
requested pursuant to section 65-3.5 of this subpart (11 NYCRR 65-3.8(a)(1). Any additional
verification required by the insurer to establish proof of claim shall be requested within 15
business days of receipt of the prescribed verification forms. Any requests by an insurer for
additional verification need not be made on any prescribed or particular form (see, 11 NYCRR
65-3.5). At a minimum, if any requested verifications has not been supplied to the insurer 30
calendar days after the original request, the insurer shall, within 10 calendar days, follow up with
the party from whom the verification was requested, either by telephone call, properly
documented in the file, or by mail. At the same time the insurer shall inform the applicant and
such person’s attorney of the reason(s) why the claim is delayed by identifying in writing the
missing verification and the party from whom it was requested. (11 NYCRR 65-3.6).
Respondent received the disputed bill in the amount of $2,510.41 from Applicant for
medical services allegedly provided to Randyshnel L Stevens on 11/30/22. The bill in dispute
was received by the Respondent on 1/12/23. It is Respondent’s regular business practice and
Respondent’s business duty to ensure all documents are stamped with the date on which they are
received and the computer records are simultaneously updated on that date. With respect to the
subject bill, normal office procedures were followed and the subject bill was stamped received
and the computer records were updated on 1/12/23. Pursuant to 11 NYCRR 65-3.5 and 65-3.6,
on 1/24/23 and 2/27/23, Respondent sent Applicant and Applicant’s assignor verification
requests for a copy of the no-fault application sent to the injured party and an executed NFAOB
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or NF-5. To date, a copy of the no-fault application has not been received by Respondent. Hence,
the claim is not overdue, the instant claim is premature and must be dismissed.
Furthermore, Respondent is not required to pay, deny, or delay the claims until the receipt
of the No-Fault Application. Applicant’s assignor failed to submit a properly executed No-Fault
Application within 30 days of the alleged accident, therefore, the assignor is disqualified as an
eligible injured person and cannot seek reimbursement of no-fault benefits.
On January 17, 2003, the Office of General Counsel issued an Opinion Letter
representing the position of the Insurance Department. The opinion letter clearly stated
“Therefore, in the question posed by the inquirer, when the No-Fault insurer receives a claim for
health services rendered from a health provider, but has not received the required application for
benefits from the eligible injured person, the No-Fault insurer is required to notify and forward
the application to the eligible injured person, for completion and submission to the insurer in a
timely manner, so that the provider may be reimbursed.” Respondent took all the necessary steps
in processing this claim in accordance with the no-fault regulations.
Written notice requirement is a predicate for coverage. If the claimant does not file a
properly executed no-fault applicant (NF-2) within 30 days of the alleged accident or written
proof providing clear and reasonable justification for the failure to comply with such time
limitation, the assignor is disqualified as an eligible injured person. Therefore, upon receipt of
Applicant’s submission of its bills for payment, the Respondent was not required to pay, deny, or
delay the claim until the receipt of the properly executed No-Fault Application, thereby making
the assignor an eligible injured person entitled to no-fault benefits.
Furthermore, 11 NYCRR65-3.5(g) states: “In lieu of a prescribed application for motor
vehicle no-fault benefits submitted by an applicant and a verification of hospital treatment (NYS
form NF-4), an insurer shall accept a completed hospital facility form (NYS form NF-5) (or an
NF-5 and uniform billing form [UBF-1] which together supply all the information requested by
the NF-5) submitted by a provider of health services with respect to the claim of such provider.”
Moreover, 11 NYCRR 65-3.5 (f) states: "[a]n insurer must accept proof of claim submitted on a
form other than a prescribed form if it contains substantially the same information as the
prescribed form". Here, Applicant failed to submit either a prescribed NF-5 form or an NF-5 and
a UBF-1. At no point was the required no-fault application received. The New York State
Department of Financial Services has established a prescribed NF-5 Form. Key information that
is required on an NF-5 form is not included in Applicant’s bill including, the type of vehicle
allegedly involved in the automobile accident, place of accident, description of the accident,
signature of the patient and or whether treatment was rendered as a result of the injury or
employment.
The Appellate Division has specifically held that: “[t]he regulation does not state that a
UBF-1/UB-04 form alone must be treated as the "functional equivalent" of an N-F 5 form.”
Sounds Shore Med. Ctr. v. New York Cent. Mut. Fire Ins. Co., 106 AD3d 157, 162 (App. Div. 2d
2013). The Court further held: “that the UB-04 form did not include the policy number, a
description of the accident, or the admitting and discharge diagnosis ... Accordingly, we do not
agree with the Appellate Term's conclusion that a UB-04 form is the "functional equivalent" of
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an N-F 5 form (see 11 NYCRR 65-3.5 [f]).” Id.
Thus, as neither an NF-2, NF-5 or functional equivalent of an NF-5 was received by
Respondent, Respondent had no duty to pay, deny or toll the claim until receipt of the application
for no-fault benefits. Respondent properly tolled Applicant’s claim.
Proof of proper mailing gives rise to a presumption that the item was received by the
addressee. This presumption may be created by proof of a standard office practice or procedure
designed to ensure that items are properly addressed and mailed (Residential Holding Corp. v.
Scottsdale Ins. Co., 286 A.D.2d 679, 729 N.Y.S.2d 776 [2 Dept.2001], see also, Matter of
Rodriguez v. Wing, 251 A.D.2d 335, 336 [1998]; Amaze Med. Supply Inc. v. Allstate Ins. Co., 2
Misc. 2d 138 [A], 2004 N.Y. Slip Op 50264 [U]).
Compliance with Respondent’s policy of mailing is sufficient as a matter of law to prove
that the verifications were mailed on the date set forth on the verifications (see, Nassau Ins. Co.
v. Murray, 46 N.Y.2d 828). The presumption that the item was received by the addressee is
created by proof of a standard procedure designed to ensure that items are properly addressed
and mailed (Tracy v. William Penn Life Ins. Co. of N.Y., 234 A.D.2d 745, 650 N.Y.S.2d 907).
Applicant does not dispute the validity and timeliness of Respondent’s verification
requests.
Based upon the foregoing, Applicant’s claim is premature as Respondent has not received
the requested verification documentation.
Thank you for your consideration. If you have any questions please feel free to contact
the undersigned at 718-238-9555.
Very truly yours,
Kristina OShea, Esa.
FILLED HMOND ni nw
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NY i ioc. NO. 6 RECEIVED NYSCEF: 05/03/2024
Ce 06126 Page 1 of 1
7 New York Central Mutual Fire Insura
HEALTH INSURANCE CLAIM FORM 1899 Central Plaza East
APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 Edmeston NY 13335
PICA . 741. PICA [TT |
1 MEDICARE MEDICAID TRICARE CHAMPVA, GROI
iste
OTHER] ta. INSURED'S 1.0. NUMBER (For Program in item1)
(ibeMH
) PLAN
a
[__] mecicarer) [| Medicaiay [] «iowo0#) [_] eemberiow
[7] ( [x]qon 071725123
2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH SEX 4. INSURED’S NAME (Last Name, First Name, Middie Initial)
STEVENS, RANDNYSHEL
5. PATIENT'S ADDRESS (No., Street)
02/19 1987
6. PATIENT RELATIONSHIP TO INSURED
m[_] Fx] STEVENS, RANDNYSHEL
7. INSURED'S ADDRESS (No., Street)
219 CAMBRIDGE AVE sotx] Spouse[ nif] oter[_] 219 CAMBRIDGE AVE
ciTy ‘STATE ‘8, RESERVED FOR NUCC USE CIty ‘STATE
BUFFALO NY BUFFALO NY
ZIP CODE ‘TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code)
14215-3735 ( ) 14215-3735 ( )
9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER
20225061971
‘a. OTHER INSURED’S POLICYOR GROUP NUMBER, a, EMPLOYMENT? (Current or Previous) '& INSURED'S DATE OF BIRTH SEX
b. RESERVED FOR NUCC USE
YES
b. AUTO ACCIDENT?
[no 02! 19 |1987 mie] Ex]
PLACE (State) |P. OTHER CLAIM 1D (Designated by NUCO)
[x]ves [1° wy, ¥4/ 20225061971
‘¢. RESERVED FOR NUCC USE ¢. OTHER ACCIDENT? ¢. INSURANCE PLAN NAME OR PROGRAM NAME
(ves [x]xo
d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCG) . IS THERE ANOTHER HEALTH BENEFIT PLAN?
Clves [Jno If yes, complete items 9, 9a, and Od.
READ BACK OF FORM BEFORE COMPLETING& SIGNING THIS FORM, 18. INSURED’S OR AUTHORIZED PERSON'S SIGNATURE | authorize
12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE | authorizethe release of any medical or other information necessary Bayment of medical benefits tothe undersigned physician or supplier for
{2.process this claim. | also request payment of goverment benefits ether to myself o tothe party who accepts assignment
SIGNED__Signature On File DATE, 11/30/2022 SIGNED tur On Fil
“aa OBSURPENT ILLNE IESS, INJURY, ot PREGNANCY (LMP) | 15. OTHER Dat TE 16. DATES: FAPNEBMOE J WORK I IN CURRENT OC U PATION
1 ee yy
QUAL| 439 QUAL!
L {i To 1| I
17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. OSPTT PATI DATES RELATED TO aE Eves,
' _
17b.| NPI Fi 1 tL TO 1 |
76, ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? ‘$ CHARGES
21. DIAGNOSISOR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24) [ves [Jv |
22. RESUBMISSION
100 ind. 0 |
ORIGINAL REF. NO.
A IS3690XA BL 1 ol
el Bie al 23. PRIOR AUTHORIZATION NUMBER
Bae
tole bes ih Lich
24 A DATE(S) OF SERVICE 8. C. D. PROCEDURES, SERVICES, OR SUPPLIES T
(Explain Unusual Circumstances) pays. J.
MM DD yw MM __DD DIAGNOSIS. 10. RENDERING
yy Senice| EMG CPTIHCPCS 1 MODIFIER POINTER S CHARGES QUAL. PROVIDER ID. #
| retOB] 31149
een ot
11/30 tL 22 | a4) 0 |22 | A0427 | 4a| | sx} Ja 2471142 | NPI 1366419509
2 1
1/30 11 22| a1! 0 |22 OB} 31149 Je
|. aoa25 | 43| |_sx| 38199| NPI[a 1366419509
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25. FEDERAL TAX NUWBEA ‘SSN EIN 26. PATIENT'S ACCOUNT NO. 7. ACCEPT, IGNMENT? [28. TOTAL CHARGE (29. AMOUNT PAID 30. isvd for NUCC Use
as
31. SIGNATURE
C)
OF PHYSICIAN OR SUPPLIER
5722211705700 YES
| 82. SERVICE FACILITY LOCATION INFORMATION
NO $ 2510,41| s 0100 1
1|
INCLUDING DEGREES OR CREDENTIALS: 93. BILLING PROVIDER INFO & PH # ( 561) 429-8265
| PROM: 1107 MAIN sT
(certify that the statements on the reverse BUFFALO NY 14209 LASALLE AMBULANCE Inc.
‘apply to this bill and are made a part thereof.) P © BOX 100296
31149 TO: 818 ELLICOTT sT
LASALLE AMBULANCE INC., L BUFFALO NY 14203 ATLANTA GA 30384-0296
193/23
SIGNED je
E
A GOSB219SQQ
* 1366419509
WPH110CL8PR ers Qrors 0on aorseen 1eer72 APPROVED OMB-0938-1197 FORM 150
: INDEX NO 85102/2024
NYSCEF DOC. NO. 6 RECEIVED NYSCEF 05/03/2024
nn y' cm
New York Central Mutual Fire Insurance Company
1899 Central Plaza East, Edmeston NY 13335-1899
INSURANCE 800-234-6926 nycm.com.
01/24/2023
LASALLE AMBULANCE INC
PO BOX 100296 Bill No: 220050750
ATLANTA GA 30384 Bill No:
Bill No:
Re: Policy No: 80234664 Acct No.: 5722211705700
11/30/2022 Patient: RANDNYSHELLE STEVENS
Our File: 2022506197-1
Agent: 3R 7050 PCA PEARL INSURANCE AGENCY
Insured: RANDNYSHELLE STEVENS
In reference to the above captioned file, to consider this claim for New York State no-fault, we
are in need of the following additional verification:
Awaiting no-fault application sent to the injured party.
No-fault forms returned, lack required information.
Hospital treatment form has not been returned by provider.
Attending physician form has not been returned from
If you indicated the patient assigned medical benefits, we require an executed
NFAOB (or equivalent) or authorization to pay benefits in compliance with
Regulation 68.
“t Forward x-ray report(s) and results for services rendered on
Bill was submitted over the 45 days allowed by Regulation 68-A. Please provide
clear and reasonable justification as to why it was submitted late.
Forward comprehensive/consultation report for services rendered
Forward ER and lab report for services rendered
Forward Operative report for services rendered
Forward doctor’s notes for services rendered
Forward no-fault coded and rated bill for services rendered
Forward MVA relation of treatment rendered on
Claim for date of service 11/30/22 is delayed awaitin;
no-fault application from RANDNYSHELLE STEVENS or
completed NF5 forms
Upon receipt of the above, we will continue to process this claim.
Very truly yours,
Alisha A. Franklin RANDNYSHELLE STEVENS
No Fault Examiner III
AAF:aaf
L14M (04/13)
: INDEX NO 85102/2024
NYSCEF DOC. NO. 6 RECEIVED NYSCEF 05/03/2024
n y' cm
New York Central Mutual Fire Insurance Company
1899 Central Plaza East, Edmeston NY 13335-1899
INSURANCE 800-234-6926 nycm.com.
02/27/2023
LASALLE AMBULANCE INC
PO BOX 100296 Bill No: 220050750
ATLANTA GA 30384 Bill No:
Bill No:
FOLLOW UP REQUEST
Re Policy No: 80234664 Acct No.: 5722211705700
D/L: 11/30/2022 Patient: RANDNYSHELLE STEVENS
Our File: 2022506197-1
Agent: 3R 7050 PCA PEARL INSURANCE AGENCY
Insured: RANDNYSHELLE STEVENS
In reference to the above captioned file, to consider this claim for New York State no-fault, we
are in need of the following additional verification:
Awaiting no-fault application sent to the injured party.
No-fault forms returned, lack required information.
Hospital treatment form has not been returned by provider.
Attending physician form has not been returned from
If you indicated the patient assigned medical benefits, we require an executed
NFAOB(or equivalent) or authorization to pay benefits in compliance with
Regulation 68.
G4 Forward x-ray report(s) and results for services rendered on
Bill was submitted over the 45 days allowed by Regulation 68-A. Please provide
clear and reasonable justification as to why it was submitted late.
Forward comprehensive/consultation report for services rendered
Forward ER and lab report for services rendered
Forward Operative report for services rendered
Forward doctor’s notes for services rendered
Forward no-fault coded and rated bill for services rendered
Forward MVA relation of treatment rendered on
Claim for date of service 11/30/22 is delayed awaiting
no-fault application from RANDNYSHELLE STEVENS or
completed NF5 forms
Upon receipt of the above, we will continue to process this claim.
Very truly yours,
Alisha A. Franklin RANDNYSHELLE STEVENS
No Fault Examiner III
AAF:aaf
L14MU (04/13)
iD: HMOND PK WV INDEX NO. 85102/2024
OUN Y:4
NYSCEF BOC. NO. 6 RECEIVED NYSCEF: 05/03/2024
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
COVER LETTER
NEW YORK CENTRAL MUTUAL ALISHA A. FRANKLIN
FIRE INSURANCE COMPANY NEW YORK CENTRAL MUTUAL
1899 CENTRAL PLAZA EAST 1899 CENTRAL PLAZA EAST
EDMESTON NY 13335-1899 EDMESTON NY 13335-1899
800-234-6926
TELEPHONE: 800-234-6926
DATE POLICYHOLDER POLICY NUMBER | DATE OF ACCIDENT | CLAIM NUMBER
12/30/2022 STEVENS,RA 80234664 11/30/2022 2022506197-1
RANDNYSHELLE STEVENS COMPLETE THE ATTACHED DB-450 FORM
219 CAMBRIDGE AVE IMMEDIATELY IF YOU ARE ENTITLED TO NEW
BUFFALO NY 14215-3735 YORK STATE DISABILITY BENEFITS AND MAIL OR
GIVE IT TO YOUR EMPLOYER. TO FIND OUT IF
YOU ARE ELIGIBLE, TELEPHONE THE NEW YORK
STATE DISABILITY BENEFITS BUREAU AT (800) 353
3092
DEAR APPLICANT:
This will acknowledge receipt of notice that you may have sustained injuries in the above captioned accident. The New
York No-Fault Law provides for the payment of benefits to victims of motor vehicle accidents to reimburse them for
their basic economic loss. Briefly summarized, basic economic loss consists of up to $50,000 per person in benefits for
the following:
a. all necessary doctor and hospital bills and other health service expenses, payable in accordance with fee
schedules established or adopted by the New York State Department of Financial Services;
b. 80% of lost earnings up to a maximum monthly payment of $2,000 for up to three years following the date of
the accident;
up to $25 per day for a period of one year from the date of the accident for other reasonable and necessary
expenses the injured person may have incurred because of an injury resulting from the accident, such as the
cost of hiring a housekeeper or necessary transportation expenses to and from a health service provider; and
a $2,000 death benefit, payable to the estate of a covered person, in addition to the $50,000 coverage for
economic loss described above.
Additional benefits may be owed to you if the above policy has been endorsed to include Optional Basic Economic Loss
coverage and/or Additional Personal Injury Protection coverage.
In determining the benefits payable to you under the No-Fault Law, amounts recovered or recoverable on account of the
accident from Workers' Compensation, New York State Disability, and certain wage continuation plans will reduce your
No-Fault benefits. Therefore, if you are entitled to any of these benefits you should make your claim for them promptly.
If you are a named insured or relative under a Mandatory Personal Injury Protection policy which includes OBEL
coverage, you may be entitled to an additional $25,000 of Basic Economic Loss coverage. You should make your claim
to that motor vehicle insurer promptly, but in no event later than 90 days after your $50,000 of Basic Economic Loss
coverage under this policy is exhausted.
NOTE: The No-Fault Law provides that if you are injured on a bus or a school bus in New York State, No-Fault benefits
must be paid by your auto insurer or if you have no auto, the auto insurer of a relative with whom you reside. The law
further provides that you should only file a No-Fault claim with the insurer of the bus or school bus if there is no such
auto policy in your household. If the above rule does not apply, you may file a No-Fault claim with the insurer of the bus
or school bus if you are the operator, owner or employee of the owner of the bus company.
NYS FORM NF-1A (Rev 6/2013)
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NYSCEF BOC. NO. 6 RECEIVED NYSCEF: 05/03/2024
COVER LETTER--PAGE TWO
To enable us to determine if you are entitled to any No-Fault benefits, please complete and immediately return the enclosed
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS (NYS FORM NF-2) along with copies of any bills you
have received to date. This application must be sent to us within 30 days of the accident date if your original notice to us
was not in writing.
You are entitled to receive health service benefits without any time limit if it is possible to determine during the
first year after the accident that further health services may be required after the first year. As you receive
additional medical bills or any other bills you believe to be covered, send them to us immediately. In order to be
considered for payment, all bills for health care services must be submitted within 45 days of treatment. If it is
not possible for you or your health care provider to submit these bills within that time period, submit a written
explanation of the reason for the delay. Claims for lost earnings and other reasonable and necessary expenses
must be submitted within 90 days. We will reimburse you as soon as we are able to verify that they are covered
expenses under No-Fault. Please identify all communications with us with the claim number shown above.
Should you have any questions concerning your claim, we will be most happy to assist you. Please feel free to
call the claim representative at the phone number provided at the top of page one.
PLEASE NOTE THAT THE TIME ALLOWED FOR PROVIDING NOTICE AND PROOF OF CLAIM TO YOUR
INSURER HAS BEEN REDUCED. FAILURE TO RETURN A COMPLETED APPLICATION FOR MOTOR
VEHICLE NO-FAULT BENEFITS FORM (NF-2) TO YOUR INSURER TIMELY CAN RESULT IN LOSS OF ALL
BENEFITS. FAILURE TO SUBMIT BILLS FOR HEALTH CARE SERVICES WITHIN 45 DAYS OF
TREATMENT OR MAKE CLAIM FOR LOST EARNINGS OR OTHER REASONABLE AND NECESSARY
EXPENSES WITHIN 90 DAYS OF OCCURRENCE CAN RESULT IN THOSE BENEFITS BEING DENIED. If
your insurer denies coverage for failure to make a timely submission you can provide them with a written reply
stating why you could not reasonably meet the time frames and your insurer must consider it.
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.
Very truly yours,
IMPORTANT REMINDERS
PLEASE ANSWER ALL QUESTIONS ON THE APPLICATION FORM AND SIGN BOTH
AUTHORIZATIONS SO THAT WE MAY GIVE PROMPT ATTENTION TO YOUR CLAIM
NYS FORM NF-1A (Rev 6/2013)
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NYSCEF BOC. NO. 6 RECEIVED NYSCEF: 05/03/2024
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS
NEW YORK CENTRAL MUTUAL ALISHA A. FRANKLIN
FIRE INSURANCE COMPANY NEW YORK CENTRAL MUTUAL
1899 CENTRAL PLAZA EAST 1899 CENTRAL PLAZA EAST
EDMESTON NY 13335-1899 EDMESTON NY 13335-1899
Telephone: 800-234-6926
Date Policyholder Policy Number Date of Accident Claim Number
12/30/2022 STEVENS, RA 80234664 11/30/2022 2022506197-1
TO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE NEW YORK NO-FAULT
LAW, PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY.
IMPORTANT: 1
TO BE ELIGIBLE FOR BENEFITS YOU MUST COMPLETE AND SIGN THIS APPLICATION.
2.
YOU MUST SIGN ANY ATTACHED AUTHORIZATION(S).
3
RETURN PROMPTLY WITH COPIES OF ANY BILLS YOU HAVE RECEIVED TO DATE.
Name and Address of Applicant
RANDNYSHELLE STEVENS
219 CAMBRIDGE AVE
BUFFALO NY 14215-3735
. Your Name 2. Phone Nos. Home Business
3. Your Address (No.,Street,City or Town and Zip Code) 4. Date of Birth 5. Social Security No.
6. Date and Time of Accident 7. Place of Accident (Street), City or Town and State
A.M.
P.M.
8. Brief Description of Accident
9. Describe Your Injury
10. Identity of Vehicle you Occupied or Operated at the Time of the Accident:
Owner's Name Make Year
This Vehicle was: L] A Bus or School Bus, CJ A Truck, (J An Automobile,
L] Or A Motorcycle
YES NO
11. Were You the Driver of the Motor Vehicle?
Were You a Passenger in the Motor Vehicle? QO
Were You a Pedestrian? QO
Were You a Member of Our Policyholder's Household? QO
Do You or a Relative with Whom You Reside Own a Motor Vehicle? O
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NYS FORM NF-2(Rev 1/2004)
Page 1 of 3
UM
203202250619710027400111162
vm 0M
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APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS--PAGE TWO
12. Were You Treated by a Doctor(s) or Other Person(s) Furnishing Health Services? Yes [_] No L]
If Yes, Name and Address of Such Doctor(s) or Person(s):
13. If You Were Treated at a Hospital(s), Were You an Out-Patient _] In-Patient L]
Date of Admission: Hospital’s Name and Address:
14. Amount of Health Bills 15. Will You Have More 16. At the Time of Your Accident Were you In the Course
Health Treatment(s)? of Your Employment?
To Date $ Yes No Yes No
O OO Oo O
17. Did You Lose Time Date Absence From Have You Returned to Work?
From Work? Work Began: Yes oO No
Yes C] NoLJ
If Yes, Date Returned to Work: Amount of Time Lost From Work:
18. What Are Your Gross Average Number of Days You Work Number Of Hours You Work
Weekly Earnings? per Week: Per Day:
19. Were You Receiving Unemployment Benefits at the Time of the Accident? Yes [] No L]
20. List Names & Address of Your Employer & Other Employers for one year Prior to Accident Date and Give
Occupation and Dates of Employment:
Employer and Address Occupation From To
Employer and Address Occupation From To
Employer and Address Occupation From To
21. As a result of your injury have you had any other expenses? Yes [] No L]
If yes, attach explanation and amounts of such expenses.
22. Due to this accident have you received or are you eligible for payments under any of the following:
ES Ne
New York State Disability? Oo O
Workers' Compensation? Oj 0
CONTINUATION ON NEXT PAGE
NYS FORM NF-2(Rev1/2004)
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NYSCEF BOC. NO. 6 RECEIVED NYSCEF: 05/03/2024
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS--PAGE THREE
The applicant authorizes the insurer to submit any and all of these forms to another party or insurer if such is necessary to
perfect its rights of rec
Preview
INDEX NO. 85102/2024 NYSCEF DOC. NO. 6 RECEIVED NYSCEF: 05/03/2024 GULLO & ASSOCIATES, LLC. ATTORNEYS AT LAW 1265 Richmond Avenue Staten Island, New York 10314 Tel: (718) 238-9555 Fax: (718) 238-9552 American Arbitration Association 120 Broadway - 11" Floor New York, New York 10271 Attention: Arbitration Team#6 Re: AAA Case No.: 41-23-1291-5441 Applicant: Lasalle Ambulance Inc Applicant Representative: Super Associates PC Respondent: New York Central Mutual Fire Insurance Company Respondent Representative: Gullo & Associates, LLC Injured Party(ies): Randyshnel L Stevens Date of Accident: 11/30/22 Dates of Service: 11/30/22 Amount in Dispute: 2,510.00 Claim #: 2022-506197-1 Our File No.: NYCM.NF-31225 The following bill must be dismissed as premature No-Fault benefits are overdue if not paid within 30 calendar days after the insurer receives proof of claim, which shall include verification of all of the relevant information requested pursuant to section 65-3.5 of this subpart (11 NYCRR 65-3.8(a)(1). Any additional verification required by the insurer to establish proof of claim shall be requested within 15 business days of receipt of the prescribed verification forms. Any requests by an insurer for additional verification need not be made on any prescribed or particular form (see, 11 NYCRR 65-3.5). At a minimum, if any requested verifications has not been supplied to the insurer 30 calendar days after the original request, the insurer shall, within 10 calendar days, follow up with the party from whom the verification was requested, either by telephone call, properly documented in the file, or by mail. At the same time the insurer shall inform the applicant and such person’s attorney of the reason(s) why the claim is delayed by identifying in writing the missing verification and the party from whom it was requested. (11 NYCRR 65-3.6). Respondent received the disputed bill in the amount of $2,510.41 from Applicant for medical services allegedly provided to Randyshnel L Stevens on 11/30/22. The bill in dispute was received by the Respondent on 1/12/23. It is Respondent’s regular business practice and Respondent’s business duty to ensure all documents are stamped with the date on which they are received and the computer records are simultaneously updated on that date. With respect to the subject bill, normal office procedures were followed and the subject bill was stamped received and the computer records were updated on 1/12/23. Pursuant to 11 NYCRR 65-3.5 and 65-3.6, on 1/24/23 and 2/27/23, Respondent sent Applicant and Applicant’s assignor verification requests for a copy of the no-fault application sent to the injured party and an executed NFAOB INDEX NO. 85102/2024 NYSCEF DOC. NO. 6 RECEIVED NYSCEF: 05/03/2024 or NF-5. To date, a copy of the no-fault application has not been received by Respondent. Hence, the claim is not overdue, the instant claim is premature and must be dismissed. Furthermore, Respondent is not required to pay, deny, or delay the claims until the receipt of the No-Fault Application. Applicant’s assignor failed to submit a properly executed No-Fault Application within 30 days of the alleged accident, therefore, the assignor is disqualified as an eligible injured person and cannot seek reimbursement of no-fault benefits. On January 17, 2003, the Office of General Counsel issued an Opinion Letter representing the position of the Insurance Department. The opinion letter clearly stated “Therefore, in the question posed by the inquirer, when the No-Fault insurer receives a claim for health services rendered from a health provider, but has not received the required application for benefits from the eligible injured person, the No-Fault insurer is required to notify and forward the application to the eligible injured person, for completion and submission to the insurer in a timely manner, so that the provider may be reimbursed.” Respondent took all the necessary steps in processing this claim in accordance with the no-fault regulations. Written notice requirement is a predicate for coverage. If the claimant does not file a properly executed no-fault applicant (NF-2) within 30 days of the alleged accident or written proof providing clear and reasonable justification for the failure to comply with such time limitation, the assignor is disqualified as an eligible injured person. Therefore, upon receipt of Applicant’s submission of its bills for payment, the Respondent was not required to pay, deny, or delay the claim until the receipt of the properly executed No-Fault Application, thereby making the assignor an eligible injured person entitled to no-fault benefits. Furthermore, 11 NYCRR65-3.5(g) states: “In lieu of a prescribed application for motor vehicle no-fault benefits submitted by an applicant and a verification of hospital treatment (NYS form NF-4), an insurer shall accept a completed hospital facility form (NYS form NF-5) (or an NF-5 and uniform billing form [UBF-1] which together supply all the information requested by the NF-5) submitted by a provider of health services with respect to the claim of such provider.” Moreover, 11 NYCRR 65-3.5 (f) states: "[a]n insurer must accept proof of claim submitted on a form other than a prescribed form if it contains substantially the same information as the prescribed form". Here, Applicant failed to submit either a prescribed NF-5 form or an NF-5 and a UBF-1. At no point was the required no-fault application received. The New York State Department of Financial Services has established a prescribed NF-5 Form. Key information that is required on an NF-5 form is not included in Applicant’s bill including, the type of vehicle allegedly involved in the automobile accident, place of accident, description of the accident, signature of the patient and or whether treatment was rendered as a result of the injury or employment. The Appellate Division has specifically held that: “[t]he regulation does not state that a UBF-1/UB-04 form alone must be treated as the "functional equivalent" of an N-F 5 form.” Sounds Shore Med. Ctr. v. New York Cent. Mut. Fire Ins. Co., 106 AD3d 157, 162 (App. Div. 2d 2013). The Court further held: “that the UB-04 form did not include the policy number, a description of the accident, or the admitting and discharge diagnosis ... Accordingly, we do not agree with the Appellate Term's conclusion that a UB-04 form is the "functional equivalent" of INDEX NO. 85102/2024 NYSCEF DOC. NO. 6 RECEIVED NYSCEF: 05/03/2024 an N-F 5 form (see 11 NYCRR 65-3.5 [f]).” Id. Thus, as neither an NF-2, NF-5 or functional equivalent of an NF-5 was received by Respondent, Respondent had no duty to pay, deny or toll the claim until receipt of the application for no-fault benefits. Respondent properly tolled Applicant’s claim. Proof of proper mailing gives rise to a presumption that the item was received by the addressee. This presumption may be created by proof of a standard office practice or procedure designed to ensure that items are properly addressed and mailed (Residential Holding Corp. v. Scottsdale Ins. Co., 286 A.D.2d 679, 729 N.Y.S.2d 776 [2 Dept.2001], see also, Matter of Rodriguez v. Wing, 251 A.D.2d 335, 336 [1998]; Amaze Med. Supply Inc. v. Allstate Ins. Co., 2 Misc. 2d 138 [A], 2004 N.Y. Slip Op 50264 [U]). Compliance with Respondent’s policy of mailing is sufficient as a matter of law to prove that the verifications were mailed on the date set forth on the verifications (see, Nassau Ins. Co. v. Murray, 46 N.Y.2d 828). The presumption that the item was received by the addressee is created by proof of a standard procedure designed to ensure that items are properly addressed and mailed (Tracy v. William Penn Life Ins. Co. of N.Y., 234 A.D.2d 745, 650 N.Y.S.2d 907). Applicant does not dispute the validity and timeliness of Respondent’s verification requests. Based upon the foregoing, Applicant’s claim is premature as Respondent has not received the requested verification documentation. Thank you for your consideration. If you have any questions please feel free to contact the undersigned at 718-238-9555. Very truly yours, Kristina OShea, Esa. FILLED HMOND ni nw OUN Y:4 NY i ioc. NO. 6 RECEIVED NYSCEF: 05/03/2024 Ce 06126 Page 1 of 1 7 New York Central Mutual Fire Insura HEALTH INSURANCE CLAIM FORM 1899 Central Plaza East APPROVED BY NATIONAL UNIFORM CLAIM COMMITTEE (NUCC) 02/12 Edmeston NY 13335 PICA . 741. PICA [TT | 1 MEDICARE MEDICAID TRICARE CHAMPVA, GROI iste OTHER] ta. INSURED'S 1.0. NUMBER (For Program in item1) (ibeMH ) PLAN a [__] mecicarer) [| Medicaiay [] «iowo0#) [_] eemberiow [7] ( [x]qon 071725123 2. PATIENT'S NAME (Last Name, First Name, Middle Initial) 3. PATIENT'S BIRTH SEX 4. INSURED’S NAME (Last Name, First Name, Middie Initial) STEVENS, RANDNYSHEL 5. PATIENT'S ADDRESS (No., Street) 02/19 1987 6. PATIENT RELATIONSHIP TO INSURED m[_] Fx] STEVENS, RANDNYSHEL 7. INSURED'S ADDRESS (No., Street) 219 CAMBRIDGE AVE sotx] Spouse[ nif] oter[_] 219 CAMBRIDGE AVE ciTy ‘STATE ‘8, RESERVED FOR NUCC USE CIty ‘STATE BUFFALO NY BUFFALO NY ZIP CODE ‘TELEPHONE (Include Area Code) ZIP CODE TELEPHONE (Include Area Code) 14215-3735 ( ) 14215-3735 ( ) 9. OTHER INSURED’S NAME (Last Name, First Name, Middle Initial) 10. IS PATIENT'S CONDITION RELATED TO: 11. INSURED'S POLICY GROUP OR FECA NUMBER 20225061971 ‘a. OTHER INSURED’S POLICYOR GROUP NUMBER, a, EMPLOYMENT? (Current or Previous) '& INSURED'S DATE OF BIRTH SEX b. RESERVED FOR NUCC USE YES b. AUTO ACCIDENT? [no 02! 19 |1987 mie] Ex] PLACE (State) |P. OTHER CLAIM 1D (Designated by NUCO) [x]ves [1° wy, ¥4/ 20225061971 ‘¢. RESERVED FOR NUCC USE ¢. OTHER ACCIDENT? ¢. INSURANCE PLAN NAME OR PROGRAM NAME (ves [x]xo d. INSURANCE PLAN NAME OR PROGRAM NAME 10d. CLAIM CODES (Designated by NUCG) . IS THERE ANOTHER HEALTH BENEFIT PLAN? Clves [Jno If yes, complete items 9, 9a, and Od. READ BACK OF FORM BEFORE COMPLETING& SIGNING THIS FORM, 18. INSURED’S OR AUTHORIZED PERSON'S SIGNATURE | authorize 12, PATIENT'S OR AUTHORIZED PERSON'S SIGNATURE | authorizethe release of any medical or other information necessary Bayment of medical benefits tothe undersigned physician or supplier for {2.process this claim. | also request payment of goverment benefits ether to myself o tothe party who accepts assignment SIGNED__Signature On File DATE, 11/30/2022 SIGNED tur On Fil “aa OBSURPENT ILLNE IESS, INJURY, ot PREGNANCY (LMP) | 15. OTHER Dat TE 16. DATES: FAPNEBMOE J WORK I IN CURRENT OC U PATION 1 ee yy QUAL| 439 QUAL! L {i To 1| I 17. NAME OF REFERRING PROVIDER OR OTHER SOURCE 17a. 18. OSPTT PATI DATES RELATED TO aE Eves, ' _ 17b.| NPI Fi 1 tL TO 1 | 76, ADDITIONAL CLAIM INFORMATION (Designated by NUCC) 20. OUTSIDE LAB? ‘$ CHARGES 21. DIAGNOSISOR NATURE OF ILLNESS OR INJURY Relate A-L to service line below (24) [ves [Jv | 22. RESUBMISSION 100 ind. 0 | ORIGINAL REF. NO. A IS3690XA BL 1 ol el Bie al 23. PRIOR AUTHORIZATION NUMBER Bae tole bes ih Lich 24 A DATE(S) OF SERVICE 8. C. D. PROCEDURES, SERVICES, OR SUPPLIES T (Explain Unusual Circumstances) pays. J. MM DD yw MM __DD DIAGNOSIS. 10. RENDERING yy Senice| EMG CPTIHCPCS 1 MODIFIER POINTER S CHARGES QUAL. PROVIDER ID. # | retOB] 31149 een ot 11/30 tL 22 | a4) 0 |22 | A0427 | 4a| | sx} Ja 2471142 | NPI 1366419509 2 1 1/30 11 22| a1! 0 |22 OB} 31149 Je |. aoa25 | 43| |_sx| 38199| NPI[a 1366419509 3 | | | | 1t ae NPI aa ee | 4 | | | | | NPI 5) | | | | | NPI and 6 = titi | | t t NPI fe 25. FEDERAL TAX NUWBEA ‘SSN EIN 26. PATIENT'S ACCOUNT NO. 7. ACCEPT, IGNMENT? [28. TOTAL CHARGE (29. AMOUNT PAID 30. isvd for NUCC Use as 31. SIGNATURE C) OF PHYSICIAN OR SUPPLIER 5722211705700 YES | 82. SERVICE FACILITY LOCATION INFORMATION NO $ 2510,41| s 0100 1 1| INCLUDING DEGREES OR CREDENTIALS: 93. BILLING PROVIDER INFO & PH # ( 561) 429-8265 | PROM: 1107 MAIN sT (certify that the statements on the reverse BUFFALO NY 14209 LASALLE AMBULANCE Inc. ‘apply to this bill and are made a part thereof.) P © BOX 100296 31149 TO: 818 ELLICOTT sT LASALLE AMBULANCE INC., L BUFFALO NY 14203 ATLANTA GA 30384-0296 193/23 SIGNED je E A GOSB219SQQ * 1366419509 WPH110CL8PR ers Qrors 0on aorseen 1eer72 APPROVED OMB-0938-1197 FORM 150 : INDEX NO 85102/2024 NYSCEF DOC. NO. 6 RECEIVED NYSCEF 05/03/2024 nn y' cm New York Central Mutual Fire Insurance Company 1899 Central Plaza East, Edmeston NY 13335-1899 INSURANCE 800-234-6926 nycm.com. 01/24/2023 LASALLE AMBULANCE INC PO BOX 100296 Bill No: 220050750 ATLANTA GA 30384 Bill No: Bill No: Re: Policy No: 80234664 Acct No.: 5722211705700 11/30/2022 Patient: RANDNYSHELLE STEVENS Our File: 2022506197-1 Agent: 3R 7050 PCA PEARL INSURANCE AGENCY Insured: RANDNYSHELLE STEVENS In reference to the above captioned file, to consider this claim for New York State no-fault, we are in need of the following additional verification: Awaiting no-fault application sent to the injured party. No-fault forms returned, lack required information. Hospital treatment form has not been returned by provider. Attending physician form has not been returned from If you indicated the patient assigned medical benefits, we require an executed NFAOB (or equivalent) or authorization to pay benefits in compliance with Regulation 68. “t Forward x-ray report(s) and results for services rendered on Bill was submitted over the 45 days allowed by Regulation 68-A. Please provide clear and reasonable justification as to why it was submitted late. Forward comprehensive/consultation report for services rendered Forward ER and lab report for services rendered Forward Operative report for services rendered Forward doctor’s notes for services rendered Forward no-fault coded and rated bill for services rendered Forward MVA relation of treatment rendered on Claim for date of service 11/30/22 is delayed awaitin; no-fault application from RANDNYSHELLE STEVENS or completed NF5 forms Upon receipt of the above, we will continue to process this claim. Very truly yours, Alisha A. Franklin RANDNYSHELLE STEVENS No Fault Examiner III AAF:aaf L14M (04/13) : INDEX NO 85102/2024 NYSCEF DOC. NO. 6 RECEIVED NYSCEF 05/03/2024 n y' cm New York Central Mutual Fire Insurance Company 1899 Central Plaza East, Edmeston NY 13335-1899 INSURANCE 800-234-6926 nycm.com. 02/27/2023 LASALLE AMBULANCE INC PO BOX 100296 Bill No: 220050750 ATLANTA GA 30384 Bill No: Bill No: FOLLOW UP REQUEST Re Policy No: 80234664 Acct No.: 5722211705700 D/L: 11/30/2022 Patient: RANDNYSHELLE STEVENS Our File: 2022506197-1 Agent: 3R 7050 PCA PEARL INSURANCE AGENCY Insured: RANDNYSHELLE STEVENS In reference to the above captioned file, to consider this claim for New York State no-fault, we are in need of the following additional verification: Awaiting no-fault application sent to the injured party. No-fault forms returned, lack required information. Hospital treatment form has not been returned by provider. Attending physician form has not been returned from If you indicated the patient assigned medical benefits, we require an executed NFAOB(or equivalent) or authorization to pay benefits in compliance with Regulation 68. G4 Forward x-ray report(s) and results for services rendered on Bill was submitted over the 45 days allowed by Regulation 68-A. Please provide clear and reasonable justification as to why it was submitted late. Forward comprehensive/consultation report for services rendered Forward ER and lab report for services rendered Forward Operative report for services rendered Forward doctor’s notes for services rendered Forward no-fault coded and rated bill for services rendered Forward MVA relation of treatment rendered on Claim for date of service 11/30/22 is delayed awaiting no-fault application from RANDNYSHELLE STEVENS or completed NF5 forms Upon receipt of the above, we will continue to process this claim. Very truly yours, Alisha A. Franklin RANDNYSHELLE STEVENS No Fault Examiner III AAF:aaf L14MU (04/13) iD: HMOND PK WV INDEX NO. 85102/2024 OUN Y:4 NYSCEF BOC. NO. 6 RECEIVED NYSCEF: 05/03/2024 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW COVER LETTER NEW YORK CENTRAL MUTUAL ALISHA A. FRANKLIN FIRE INSURANCE COMPANY NEW YORK CENTRAL MUTUAL 1899 CENTRAL PLAZA EAST 1899 CENTRAL PLAZA EAST EDMESTON NY 13335-1899 EDMESTON NY 13335-1899 800-234-6926 TELEPHONE: 800-234-6926 DATE POLICYHOLDER POLICY NUMBER | DATE OF ACCIDENT | CLAIM NUMBER 12/30/2022 STEVENS,RA 80234664 11/30/2022 2022506197-1 RANDNYSHELLE STEVENS COMPLETE THE ATTACHED DB-450 FORM 219 CAMBRIDGE AVE IMMEDIATELY IF YOU ARE ENTITLED TO NEW BUFFALO NY 14215-3735 YORK STATE DISABILITY BENEFITS AND MAIL OR GIVE IT TO YOUR EMPLOYER. TO FIND OUT IF YOU ARE ELIGIBLE, TELEPHONE THE NEW YORK STATE DISABILITY BENEFITS BUREAU AT (800) 353 3092 DEAR APPLICANT: This will acknowledge receipt of notice that you may have sustained injuries in the above captioned accident. The New York No-Fault Law provides for the payment of benefits to victims of motor vehicle accidents to reimburse them for their basic economic loss. Briefly summarized, basic economic loss consists of up to $50,000 per person in benefits for the following: a. all necessary doctor and hospital bills and other health service expenses, payable in accordance with fee schedules established or adopted by the New York State Department of Financial Services; b. 80% of lost earnings up to a maximum monthly payment of $2,000 for up to three years following the date of the accident; up to $25 per day for a period of one year from the date of the accident for other reasonable and necessary expenses the injured person may have incurred because of an injury resulting from the accident, such as the cost of hiring a housekeeper or necessary transportation expenses to and from a health service provider; and a $2,000 death benefit, payable to the estate of a covered person, in addition to the $50,000 coverage for economic loss described above. Additional benefits may be owed to you if the above policy has been endorsed to include Optional Basic Economic Loss coverage and/or Additional Personal Injury Protection coverage. In determining the benefits payable to you under the No-Fault Law, amounts recovered or recoverable on account of the accident from Workers' Compensation, New York State Disability, and certain wage continuation plans will reduce your No-Fault benefits. Therefore, if you are entitled to any of these benefits you should make your claim for them promptly. If you are a named insured or relative under a Mandatory Personal Injury Protection policy which includes OBEL coverage, you may be entitled to an additional $25,000 of Basic Economic Loss coverage. You should make your claim to that motor vehicle insurer promptly, but in no event later than 90 days after your $50,000 of Basic Economic Loss coverage under this policy is exhausted. NOTE: The No-Fault Law provides that if you are injured on a bus or a school bus in New York State, No-Fault benefits must be paid by your auto insurer or if you have no auto, the auto insurer of a relative with whom you reside. The law further provides that you should only file a No-Fault claim with the insurer of the bus or school bus if there is no such auto policy in your household. If the above rule does not apply, you may file a No-Fault claim with the insurer of the bus or school bus if you are the operator, owner or employee of the owner of the bus company. NYS FORM NF-1A (Rev 6/2013) Page 1 of 2 iD: HMOND PK WV INDEX NO. 85102/2024 OUN Y:4 NYSCEF BOC. NO. 6 RECEIVED NYSCEF: 05/03/2024 COVER LETTER--PAGE TWO To enable us to determine if you are entitled to any No-Fault benefits, please complete and immediately return the enclosed APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS (NYS FORM NF-2) along with copies of any bills you have received to date. This application must be sent to us within 30 days of the accident date if your original notice to us was not in writing. You are entitled to receive health service benefits without any time limit if it is possible to determine during the first year after the accident that further health services may be required after the first year. As you receive additional medical bills or any other bills you believe to be covered, send them to us immediately. In order to be considered for payment, all bills for health care services must be submitted within 45 days of treatment. If it is not possible for you or your health care provider to submit these bills within that time period, submit a written explanation of the reason for the delay. Claims for lost earnings and other reasonable and necessary expenses must be submitted within 90 days. We will reimburse you as soon as we are able to verify that they are covered expenses under No-Fault. Please identify all communications with us with the claim number shown above. Should you have any questions concerning your claim, we will be most happy to assist you. Please feel free to call the claim representative at the phone number provided at the top of page one. PLEASE NOTE THAT THE TIME ALLOWED FOR PROVIDING NOTICE AND PROOF OF CLAIM TO YOUR INSURER HAS BEEN REDUCED. FAILURE TO RETURN A COMPLETED APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS FORM (NF-2) TO YOUR INSURER TIMELY CAN RESULT IN LOSS OF ALL BENEFITS. FAILURE TO SUBMIT BILLS FOR HEALTH CARE SERVICES WITHIN 45 DAYS OF TREATMENT OR MAKE CLAIM FOR LOST EARNINGS OR OTHER REASONABLE AND NECESSARY EXPENSES WITHIN 90 DAYS OF OCCURRENCE CAN RESULT IN THOSE BENEFITS BEING DENIED. If your insurer denies coverage for failure to make a timely submission you can provide them with a written reply stating why you could not reasonably meet the time frames and your insurer must consider it. 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. Very truly yours, IMPORTANT REMINDERS PLEASE ANSWER ALL QUESTIONS ON THE APPLICATION FORM AND SIGN BOTH AUTHORIZATIONS SO THAT WE MAY GIVE PROMPT ATTENTION TO YOUR CLAIM NYS FORM NF-1A (Rev 6/2013) Page 2 of 2 iD: HMOND PK WV INDEX NO. 85102/2024 OUN Y:4 NYSCEF BOC. NO. 6 RECEIVED NYSCEF: 05/03/2024 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS NEW YORK CENTRAL MUTUAL ALISHA A. FRANKLIN FIRE INSURANCE COMPANY NEW YORK CENTRAL MUTUAL 1899 CENTRAL PLAZA EAST 1899 CENTRAL PLAZA EAST EDMESTON NY 13335-1899 EDMESTON NY 13335-1899 Telephone: 800-234-6926 Date Policyholder Policy Number Date of Accident Claim Number 12/30/2022 STEVENS, RA 80234664 11/30/2022 2022506197-1 TO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE NEW YORK NO-FAULT LAW, PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY. IMPORTANT: 1 TO BE ELIGIBLE FOR BENEFITS YOU MUST COMPLETE AND SIGN THIS APPLICATION. 2. YOU MUST SIGN ANY ATTACHED AUTHORIZATION(S). 3 RETURN PROMPTLY WITH COPIES OF ANY BILLS YOU HAVE RECEIVED TO DATE. Name and Address of Applicant RANDNYSHELLE STEVENS 219 CAMBRIDGE AVE BUFFALO NY 14215-3735 . Your Name 2. Phone Nos. Home Business 3. Your Address (No.,Street,City or Town and Zip Code) 4. Date of Birth 5. Social Security No. 6. Date and Time of Accident 7. Place of Accident (Street), City or Town and State A.M. P.M. 8. Brief Description of Accident 9. Describe Your Injury 10. Identity of Vehicle you Occupied or Operated at the Time of the Accident: Owner's Name Make Year This Vehicle was: L] A Bus or School Bus, CJ A Truck, (J An Automobile, L] Or A Motorcycle YES NO 11. Were You the Driver of the Motor Vehicle? Were You a Passenger in the Motor Vehicle? QO Were You a Pedestrian? QO Were You a Member of Our Policyholder's Household? QO Do You or a Relative with Whom You Reside Own a Motor Vehicle? O CONTINUATION ON NEXT PAGE NYS FORM NF-2(Rev 1/2004) Page 1 of 3 UM 203202250619710027400111162 vm 0M INDEX NO. 85102/2024 NYSCEF DOC. NO. 6 RECEIVED NYSCEF: 05/03/2024 APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS--PAGE TWO 12. Were You Treated by a Doctor(s) or Other Person(s) Furnishing Health Services? Yes [_] No L] If Yes, Name and Address of Such Doctor(s) or Person(s): 13. If You Were Treated at a Hospital(s), Were You an Out-Patient _] In-Patient L] Date of Admission: Hospital’s Name and Address: 14. Amount of Health Bills 15. Will You Have More 16. At the Time of Your Accident Were you In the Course Health Treatment(s)? of Your Employment? To Date $ Yes No Yes No O OO Oo O 17. Did You Lose Time Date Absence From Have You Returned to Work? From Work? Work Began: Yes oO No Yes C] NoLJ If Yes, Date Returned to Work: Amount of Time Lost From Work: 18. What Are Your Gross Average Number of Days You Work Number Of Hours You Work Weekly Earnings? per Week: Per Day: 19. Were You Receiving Unemployment Benefits at the Time of the Accident? Yes [] No L] 20. List Names & Address of Your Employer & Other Employers for one year Prior to Accident Date and Give Occupation and Dates of Employment: Employer and Address Occupation From To Employer and Address Occupation From To Employer and Address Occupation From To 21. As a result of your injury have you had any other expenses? Yes [] No L] If yes, attach explanation and amounts of such expenses. 22. Due to this accident have you received or are you eligible for payments under any of the following: ES Ne New York State Disability? Oo O Workers' Compensation? Oj 0 CONTINUATION ON NEXT PAGE NYS FORM NF-2(Rev1/2004) Page 2 of 3 iD: HMOND PK WV INDEX NO. 85102/2024 OUN Y:4 NYSCEF BOC. NO. 6 RECEIVED NYSCEF: 05/03/2024 APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS--PAGE THREE The applicant authorizes the insurer to submit any and all of these forms to another party or insurer if such is necessary to perfect its rights of rec