Preview
FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019
NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020
Exhibit E
FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019
NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020
CONTACT US
By Phone
Direct: (516) 479-0624
July 20, 2018 Toll Free: (800) 470-3811/
(800) 470-3811
Ext. 71645
Fax: (603) 334-8301
By E-mail
Keneon Thomas
ronda.humphrey@
14521 Tuskegee Airmen Way libertymutual.com
Jamaica NY 11435-5119
LM General Insurance Company
P.O. Box 515097
Los Angeles, CA 90051-5097
Claim Number: LA000-037777086-04 Visit us online
LibertyMutual.com
Date of Loss: 07/05/2018
About Claims Process
Dear Keneon Thomas, Libertymutual.com/claims-
insurance/about-claims-process
As your Liberty Mutual Insurance Claims Representative, my goal is to
make your claim experience as easy and w orry-free as possible. Mobile
Scan QR Code w ith your
At this point in the claim process, I need a bit more information about iPhone or Android
smartphone to dow nload
your accident before I can move forw ard. Unfortunately, I have not the claims app or dow nload
been able to reach you. a free reader app at
w w w .i-nigma.mobi
ItIs Important That I Speak With You
Please call me as soon as possible so that I can assist you w ith your
claim. You can reach me betw een the hours of 08:00 AM and 04:15
PM.
IfI am unavailable w hen you call, please leave me a voice mail stating
the best time and number to reach you.
Thank you for your prompt response to this matter.
Sincerely,
Ronda Humphrey
Claims Department
CWL125 Page 1 of 1
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NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020
utual.
INSURANCE
CONTACT US
By Phone
Direct: (516) 479-0624
2018 TollFree:(800) 470-3811/
July 20,
(800) 470-3811
Ext. 71645
Fax: (603) 334-8301
Keneon Thomas By E-mail
ronda.humphrey@
14521 Tuskegee Airmen Way libertymutual.com
Jamaica NY 11435-5119
LM General Insurance Company
P.O. Box 515097
Los Angeles,CA 90051-5097
Insured: Regina F. Milerson visitus online
LibertyMutual.com
Claimant: Keneon Thomas
Claim Number: LA000-037777086-04
Date of Loss: 07/05/2018
Policy Number: AOS-228-236650-40
Dear Keneon Thomas,
I'llbe handling your medical claim. I'm sorry to hear about your recent
accident and hope you are feeling better soon.
Please know I willdo everything I can to make sure your claim is
processed as efficiently as possible. Below you will find instructions
on how to get your medical billspaid.
Getting Your Medical Bill Paid:
X You have successfully reported your medical claim.
Ifnecessary, seek medical treatment and present your Claim
Card (enclosed) to your medical provider.
Your medical provider will submit bills directly to Liberty
Mutual. Ifyour doctor has billingquestions, please have them
call us at 800-245-1700, ext. 724-0286.
Ifyou receive billsfrom your provider, please email them to
Imaginq@Libertymutual.com or mail them to the address on
the Claim Card.
We will notify you by mail once we've processed your bills.
I willreview your claim and contact you ifI need anything. Ifyou
have any questions during your claim experience, please email or call
me.
Ifyou have questions about your auto claim, please contact your Auto
Claim Resolution Specialist, Melissa Brady or sign into your online
account.
CWL2078 Page 1 of 3
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NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020
utual.
INSURANCE
Sincerely,
Ronda Humphrey
Claims Department
CWL2078 Page 2 of 3
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utual.
INSURANCE
Important Information Regarding Preferred Provider Network
You may be eligible to access a Preferred Provider Network (PPN) of doctors and facilitiesunder
your medical coverage provided by your personal auto policy. As explained below, this benefit is
not available in allstates.
What is a PPN and what does itmean for you? A PPN isa group of medical service providers
who have joined a network and have agreed to accept pre-arranged discounts for necessary
medical services. The PPN can help you locate a highly qualified physician in your area as each
of the PPN providers has met rigorous credentialing requirements. Ifyou presently have limited
coverage on your policy, utilizing a PPN provider can extend the limitof that coverage. As an
example assume you have $1,000 in medical coverage:
*
Not a PPN Provider PPN Provider
Medical Service Charge $1,000 $1,000
Contracted PPN Discount (20%) $0.00 $200
Final Payment to Provider $1,000 $800
Remaining Policy Coverage $0.00 $200
*
Please note that each medical providers PPN discount will be different and the services the
discounts apply to may vary. Also, there is no cost to you for this service and you are not
required to take advantage of the PPN.
For information on the Preferred Provider Network in your state please see below. In each
instance please let the network contact know you are a Liberty Mutual policyholder, the type of
treatment you are seeking and where you would liketo treat. Upon doing so you will be given the
names of the local medical providers in the network: SHOULD YOU VISIT A NETWORK
PROVIDER PLEASE TAKE THIS DOCUMENT WITH YOU.
AL, AK, AR, CA, CO, CT, DC, DE, GA, HI, IL, IN, IA, KS, KY, MO, MS, NC, ND, NE, OH, OR, PA,
SD, TN, TX, UT, VA, WA, WI, WV, WY:
Network Affiliation - Contact Auto Network or at
Coventry (1-800-330-9938)
Provider"
www.coventryautosolutions.com. Select the "Locate a link (upper right hand corner) to
search for a medical provider near you.
Louisiana, Maryland, Minnesota:
Network Affiliation - Contact Prime Health Services Network at (1-866-348-3887 x180). Hours
to call: 8:00am to 5:00pm CST - Friday. Or visittheir website at
Monday
http://libertymutual.primehealthservices.com.
Massachusetts Network Association - VNA): Network Affiliation - Contact
(Voluntary Coventry
Auto Network (1-800-330-9938) or at www.coventryautosolutions.com. Select the "Locate a
Provider"
link (upper right hand corner) to search for a medical provider near you.
Michigan:
Network Affiliation -Contact Inc. at (1-800-831-1166). Hours to call: 8:00am to 5:00pm
Cofinity,
- " Provider"
CST Monday Friday. Or visit their website at www.cofinity.net. Under the Find
"Auto"
section, select "Cofinity". From the search page, select as the insurance type.
New Jersey: Network Affiliation - Horizon Inc. (1-800-985-7777 option
Casualty Services, (HCS)
7). Hours to call: 8:00am to 5:00pm EST - Friday.
Monday
CWL2078 Page 3 of 3
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NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020
Injury Claim Card
Below are tw o copies of your “ Injury Claim Card.” These cards contain all of the pertinent information
that you w ill need to give to your Medical Providers so they can submit your medical bills to Liberty
Mutual.
The Claim Cards include your Claim number, Liberty Mutual' s mailing address and the telephone number
for Medical Bill Provider Support. If your provider has any questions about a medical bill review , they
can contact Provider Support directly.
We encourage you to keep a copy of your Claim Card in your w allet to ensure that you have all of your
claim information available at all times.
Keep this card w ith you to provide billing information to your medical providers.
Keep this card w ith you to provide billing information to your medical providers.
Liberty Mutual Claim #: LA000-037777086-04 Liberty Mutual Claim #: LA000-037777086-04
Please send medical claim forms and records to: Please send medical claim forms and records to:
PO Box 515097 PO Box 515097
Los Angeles, CA 90051-5097 Los Angeles, CA 90051-5097
For inquiries regarding a bill review : For inquiries regarding a bill review :
Medical Bill Provider Support – Medical Bill Provider Support –
800-245-1700, Ext. 724-0286 800-245-1700, Ext. 724-0286
This card is for informational purpose only and is not a guarantee of payment.
This card is for informational purpose only and is not a guarantee of payment.
CWL2124 Page 1 of 1
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NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
COVER LETTER
LM General Insurance Company * Ronda Humphrey
P.O. Box 515097 Tel: (800) 470-3811
Los Angeles, CA 90051-5097
DATE POLICYHOLDER POLICY NUMBER DATE OF ACCID CLAIM NUMBER
07/20/2018 Regina F. Milerson AOS-228-236650-40 07/05/2018 LA000-037777086-04
COMPLETE THE ATTACHED DB-450 FORM
Keneon Thomas IMMEDIATELY IF YOU ARE ENTITLED TO NEW
14521 Tuskegee Airmen Way YORK STATE DISABILITY BENEFITS AND
Jamaica NY 11435-5119 MAIL OR GIVE IT TO YOUR EMPLOYER. TO
FIND OUT IF YOU ARE ELIGIBLE,
TELEPHONE THE NEW YORK STATE
DISABILITY BENEFITS BUREAU AT (718) 802
6964
Request.
Dear Keneon Thomas:
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 Insurance Department;
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;
c) 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
d) 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.
NYS FORM NF-1A (Rev 1/2004)) NYSNF-1A
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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 us if
there is no such auto policy in your household. The above rule does not apply and you may file a No-
Fault claim with us if you are the operator, owner or employee of the owner of the bus company.
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 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 ifit 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,
Ronda Humphrey
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 1/2004) NYSNF-1A
FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019
NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS
LM General Insurance Company * Ronda Humphrey *
P.O. Box 515097 Tel: (800) 470-3811
Los Angeles, CA 90051-5097
DATE POLICYHOLDER POLICY NUMBER DATE OF ACCID CLAIM NUMBER
07/20/2018 Regina F. Milerson AOS-228-236650-40 07/05/2018 LA000-037777086-04
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.
Keneon Thomas *
14521 Tuskegee Airmen Way
Jamaica NY 11435-5119
1. YOUR NAME 2. PHONE HOME BUSINESS
NOS.
3. YOUR ADDRESS (NO., STREET, CITY OR TOWN AND ZIP CODE) 4. DATE OF BIRTH 5. SOCIAL SECURITY NO.
6. DATE AND TIME A.M. 7. PLACE OF ACCIDENT (STREET), CITY OR TOWN AND STATE
OF ACCIDENT P.M.
8. BRIEF DESCRIPTION OF ACCIDENT:
9. DESCRIBE YOUR INJURY:
10. IDENTITY OF THE VEHICLE YOU OCCUPIED OR OPERATED AT THE 11. WERE YOU THE DRIVER OF THE
TIME OF THE ACCIDENT: MOTOR VEHICLE? YES NO
OWNER'S NAME MAKE YEAR WERE YOU A PASSENGER IN THE
MOTOR VEHICLE? YES NO
WERE YOU A PEDESTRIAN? YES NO
THIS VEHICLE WAS: A BUS OR SCHOOL BUS WERE YOU A MEMBER OF OUR
POLICYHOLDER'S HOUSEHOLD? YES NO
A TRUCK, OR AN AUTOMOBILE
DO YOU OR A RELATIVE WITH WHOM
A MOTORCYCLE YOU RESIDE OWN A MOTOR VEHICLE? YES NO
12. WERE YOU TREATED BY A DOCTOR(S) OR OTHER PERSON(S) FURNISHIG HEALTH SERVICES? YES NO
NAME AND ADDRESS OF SUCH DOCTOR(S) OR PERSON(S):
13. IF YOU WERE TREATED AT HOSPITAL(S), WERE YOU AN OUT-PATIENT? IN-PATIENT?
DATE OF ADMISSION: HOSPITAL'S NAME AND ADDRESS:
14. AMOUNT OF HEALTH BILLS 15. WILL YOU HAVE MORE HEALTH 16. AT THE TIME OF YOUR ACCIDENT WERE YOU IN THE
TO DATE TREATMENT(S)? COURSE OF YOUR EMPLOYMENT?
$ YES NO YES NO
17. DID YOU LOSE TIME DATE ABSENCE FROM WORK BEGAN: HAVE YOU RETURNED IF YES, DATE RETURNED TO WORK:
FROM WORK? TO WORK?
YES NO YES NO
AMOUNT OF TIME LOST FROM WORK: 18. WHAT ARE YOUR AVERAGE WEEKLY NUMBER OF DAYS YOU NUMBER OF HOURS YOU
EARNINGS? WORK PER WEEK: WORK PER DAY:
19. WERE YOU RECEIVING UNEMPLOYMENT BENEFITS AT THE TIME OF THE ACCIDENT? YES NO
CONTINUATION ON NEXT PAGE
NYS FORM NF-2 NYSNF-2
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20. LIST NAMES AND ADDRESSES OF YOUR EMPLOYER AND OTHER EMPLOYERS FOR ONE YEAR PRIOR TO ACCIDENT DATE AND GIVE
OCCUPATION AND DATES OF EMPLOYMENT:
EMPLOYER NAME AND ADDRESS OCCUPATION FROM TO
EMPLOYER NAME AND ADDRESS OCCUPATION FROM TO
EMPLOYER NAME AND ADDRESS OCCUPATION FROM TO
21. AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES? YES NO
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:
NEW YORK STATE DISABILITY? WORKERS' COMPENSATION?
YES NO YES NO
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 RECOVERY PROVIDED FOR UNDER THE NO-FAULT LAW.
THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE
APPLICANT AS TRUE UNDER THE PENALTIES OF PERJURY
"Any person who knowingly and with intent to defraud any insurance company or other person filesan 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."
SIGNATURE: DATE:
...............................................
DO NOT DETACH
AUTHORIZATION FOR RELEASE OF WORK
AND OTHER LOSS INFORMATION
THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY
WAGES, SALARY OR OTHER LOSS WHILE EMPLOYED BY YOU. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH
THE NEWYORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW).
NAME (PRINT OR TYPE) SOCIAL SECURITY NO.
SIGNATURE DATE
...............................................
DO NOT DETACH
AUTHORIZATION FOR RELEASE OF HEALTH
SERVICE OR TREATMENT INFORMATION
THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY
CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED, X-RAYS AND PHYSICAL FINDINGS,
DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE
MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW).
NAME (PRINT OR TYPE)
SIGNATURE DATE
(IF THE APPLICANT IS A MINOR, PARENT OR GUARDIAN SHALL SIGN AND INDICATE CAPACITY AND RELATIONSHIP.)
* BRACKETED LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER
NYS FORM NF-2 NYSNF-2
FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019
NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020
CLAIM NUMBER: LA000-037777086-04
NOTICE TO NO-FAULT BENEFITS APPLICANTS
If you are eligible to receive New York State Disability Benefits as a result of this accident,
you must advise us whether or not the New York State Disability Benefits you are eligible
for are taxable. Whether or not your benefits are taxable will have an effect on the amount
of benefits you may be eligible for under your Personal Injury Protection (No-Fault) loss of
earnings benefits.
The proof necessary to establish whether or not your New York State Disability Benefits are
taxable can be one or more of the following:
1. A pay stub prior to the accident which shows you are not paying a premium for New York
State Disability Benefits.
2. A check stub for New York State Disability Benefits received which shows taxes are
withheld.
3. A W-2 form which reports Disability Benefits as income.
4. A copy of the completed DB-450 (Section C, from your employer) for this disability which
indicates the percentage of disability premium paid by the employee.
Please make sure that if you are claiming loss of earnings benefits under your Personal Injury
Protection Coverage, we are provided with one or more of the items listed above.
NYSNF-0
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NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020
VOLUNTARY NETWORK ACCESS PROGRAM
Important Information Regarding Your Automobile Accident
As part of our continuing effort to provide full service to our policyholders, Liberty Mutual has
arranged to have a Voluntary Network Access Program available to assist you in finding the
proper medical care.
If you are injured in an automobile accident, you may be eligible to receive medical care through
the Coventry Auto Network of facilities and providers. If you require medical care, you may
contact the Coventry Auto Network Provider Locator Service at 1-800-330-9938. You will be
assisted in locating a Coventry Auto Network provider near you. You may use the toll free number
shown above to call for names of providers in your area between the hours of 9:00 AM and 5:00
PM, Monday through Friday. There is also a website you can access at www.coventrywcs.com.
Click on 'CLIENT LOGIN & TOOLS'. In the Client Login in window enter Client ID ''lan''to
locate a conveniently located medical provider.
If you are interested in participating in the Voluntary Network Access Program, this is how the
program works:
Call the provider you choose, from those provided by Coventry Auto Network's Provider Locator
Service, for an appointment and state that you are a Liberty Mutual policyholder and you have been
in an auto accident. You will be given an appointment promptly. This provider will make all
necessary referrals for testing and visits to other providers, after confirming benefits with a Liberty
Mutual Claims Representative.
Your personal injury benefits and the premium you pay on your policy will not change whether
or not you select a voluntary medical provider or one of your own choice or any combination of
the above. There will be no penalties imposed if you chose a provider who is not included in the
Network.
Liberty Mutual Insurance is pleased to offer this service to you.
CWL2021-NY
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NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020
NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS
CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY
1. USE THIS FORM IF YOU BECOME SICK OR DISABLED WHILE EMPLOYED OR IF YOU BECOME SICK OR DISABLED WITHIN FOUR (4)WEEKS
AFTER TERMINATION OF EMPLOYMENT. USE CLAIM FORM DB-300 IF YOU BECOME SICK OR DISABLED AFTER HAVING BEEN
UNEMPLOYED MORE THAN FOUR (4) WEEKS.
2. YOU MUST COMPLETE ALL ITEMS OF PART A - THE " CLAIMANT'S STATEMENT." BE ACCURATE. CHECK ALL DATES.
3. BE SURE TO DATE AND SIGN YOUR CLAIM (SEE ITEM 12). IF YOU CANNOT SIGN THIS CLAIM FORM, YOUR REPRESENTATIVE MAY SIGN IT IN
YOUR BEHALF. IN THAT EVENT, THE NAME, ADDRESS AND THE REPRESENTATIVE'S RELATIONSHIP TO YOU SHOULD BE NOTED UNDER THE
SIGNATURE.
4. DO NOT MAIL THIS CLAIM UNLESS YOUR HEALTH CARE PROVIDER COMPLETES AND SIGNS PART B - THE "HEALTH CARE PROVIDER'S
STATEMENT."
5. YOUR COMPLETED CLAIM SHOULD BE MAILED WITHIN THIRTY (30)DAYS AFTER YOU BECOME SICK OR DISABLED TO YOUR LAST
EMPLOYER OR YOUR LAST EMPLOYER'S INSURANCE COMPANY .
6. MAKE A COPY OF THIS COMPLETED FORM FOR YOUR RECORDS BEFORE YOU SUBMIT IT.
PART A - CLAIMANT'S STATEMENT (Please Print or Type) ANSWER ALL QUESTIONS
1. My name is
First Middle Last Social Security Number
2. Address
Number Street City or Town State Zip Code Apt. No.
3. Tel No. 4. Date of Birth / / 5. Married (Check one) Yes No
6. My disability is (If injury, also state
how, when and where it occurred)
7. I became disabled on a. I worked on that day Yes No
Mo. Day Year
b. I have since worked for wages or profit Yes No If "Yes," give dates
8. Give name of last employer. If more than one employer during last eight (8) weeks, name all employers.
EMPLOYERS DATES OF EMPLOYMENT AVERAGE WEEKLY WAGES
BUSINESS BUSINESS TELEPHONE FROM THROUGH (Include Bonuses, Tips, Commissions,
NAME ADDRESS NUMBER
Mo. Day Year Mo. Day Year Reasonable Value of Board, Rent, etc.)
9. My job is or was
Occupation Name of Union and Local No., if Member
10. For the period of disability covered by this claim
a. Are you receiving wages, salary or separation pay: Yes No
b. Are you receiving or claiming:
(1) Workers' Compensation for work-connected disability Yes No
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FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 Exhibit E FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 CONTACT US By Phone Direct: (516) 479-0624 July 20, 2018 Toll Free: (800) 470-3811/ (800) 470-3811 Ext. 71645 Fax: (603) 334-8301 By E-mail Keneon Thomas ronda.humphrey@ 14521 Tuskegee Airmen Way libertymutual.com Jamaica NY 11435-5119 LM General Insurance Company P.O. Box 515097 Los Angeles, CA 90051-5097 Claim Number: LA000-037777086-04 Visit us online LibertyMutual.com Date of Loss: 07/05/2018 About Claims Process Dear Keneon Thomas, Libertymutual.com/claims- insurance/about-claims-process As your Liberty Mutual Insurance Claims Representative, my goal is to make your claim experience as easy and w orry-free as possible. Mobile Scan QR Code w ith your At this point in the claim process, I need a bit more information about iPhone or Android smartphone to dow nload your accident before I can move forw ard. Unfortunately, I have not the claims app or dow nload been able to reach you. a free reader app at w w w .i-nigma.mobi ItIs Important That I Speak With You Please call me as soon as possible so that I can assist you w ith your claim. You can reach me betw een the hours of 08:00 AM and 04:15 PM. IfI am unavailable w hen you call, please leave me a voice mail stating the best time and number to reach you. Thank you for your prompt response to this matter. Sincerely, Ronda Humphrey Claims Department CWL125 Page 1 of 1 FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 utual. INSURANCE CONTACT US By Phone Direct: (516) 479-0624 2018 TollFree:(800) 470-3811/ July 20, (800) 470-3811 Ext. 71645 Fax: (603) 334-8301 Keneon Thomas By E-mail ronda.humphrey@ 14521 Tuskegee Airmen Way libertymutual.com Jamaica NY 11435-5119 LM General Insurance Company P.O. Box 515097 Los Angeles,CA 90051-5097 Insured: Regina F. Milerson visitus online LibertyMutual.com Claimant: Keneon Thomas Claim Number: LA000-037777086-04 Date of Loss: 07/05/2018 Policy Number: AOS-228-236650-40 Dear Keneon Thomas, I'llbe handling your medical claim. I'm sorry to hear about your recent accident and hope you are feeling better soon. Please know I willdo everything I can to make sure your claim is processed as efficiently as possible. Below you will find instructions on how to get your medical billspaid. Getting Your Medical Bill Paid: X You have successfully reported your medical claim. Ifnecessary, seek medical treatment and present your Claim Card (enclosed) to your medical provider. Your medical provider will submit bills directly to Liberty Mutual. Ifyour doctor has billingquestions, please have them call us at 800-245-1700, ext. 724-0286. Ifyou receive billsfrom your provider, please email them to Imaginq@Libertymutual.com or mail them to the address on the Claim Card. We will notify you by mail once we've processed your bills. I willreview your claim and contact you ifI need anything. Ifyou have any questions during your claim experience, please email or call me. Ifyou have questions about your auto claim, please contact your Auto Claim Resolution Specialist, Melissa Brady or sign into your online account. CWL2078 Page 1 of 3 FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 utual. INSURANCE Sincerely, Ronda Humphrey Claims Department CWL2078 Page 2 of 3 FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 utual. INSURANCE Important Information Regarding Preferred Provider Network You may be eligible to access a Preferred Provider Network (PPN) of doctors and facilitiesunder your medical coverage provided by your personal auto policy. As explained below, this benefit is not available in allstates. What is a PPN and what does itmean for you? A PPN isa group of medical service providers who have joined a network and have agreed to accept pre-arranged discounts for necessary medical services. The PPN can help you locate a highly qualified physician in your area as each of the PPN providers has met rigorous credentialing requirements. Ifyou presently have limited coverage on your policy, utilizing a PPN provider can extend the limitof that coverage. As an example assume you have $1,000 in medical coverage: * Not a PPN Provider PPN Provider Medical Service Charge $1,000 $1,000 Contracted PPN Discount (20%) $0.00 $200 Final Payment to Provider $1,000 $800 Remaining Policy Coverage $0.00 $200 * Please note that each medical providers PPN discount will be different and the services the discounts apply to may vary. Also, there is no cost to you for this service and you are not required to take advantage of the PPN. For information on the Preferred Provider Network in your state please see below. In each instance please let the network contact know you are a Liberty Mutual policyholder, the type of treatment you are seeking and where you would liketo treat. Upon doing so you will be given the names of the local medical providers in the network: SHOULD YOU VISIT A NETWORK PROVIDER PLEASE TAKE THIS DOCUMENT WITH YOU. AL, AK, AR, CA, CO, CT, DC, DE, GA, HI, IL, IN, IA, KS, KY, MO, MS, NC, ND, NE, OH, OR, PA, SD, TN, TX, UT, VA, WA, WI, WV, WY: Network Affiliation - Contact Auto Network or at Coventry (1-800-330-9938) Provider" www.coventryautosolutions.com. Select the "Locate a link (upper right hand corner) to search for a medical provider near you. Louisiana, Maryland, Minnesota: Network Affiliation - Contact Prime Health Services Network at (1-866-348-3887 x180). Hours to call: 8:00am to 5:00pm CST - Friday. Or visittheir website at Monday http://libertymutual.primehealthservices.com. Massachusetts Network Association - VNA): Network Affiliation - Contact (Voluntary Coventry Auto Network (1-800-330-9938) or at www.coventryautosolutions.com. Select the "Locate a Provider" link (upper right hand corner) to search for a medical provider near you. Michigan: Network Affiliation -Contact Inc. at (1-800-831-1166). Hours to call: 8:00am to 5:00pm Cofinity, - " Provider" CST Monday Friday. Or visit their website at www.cofinity.net. Under the Find "Auto" section, select "Cofinity". From the search page, select as the insurance type. New Jersey: Network Affiliation - Horizon Inc. (1-800-985-7777 option Casualty Services, (HCS) 7). Hours to call: 8:00am to 5:00pm EST - Friday. Monday CWL2078 Page 3 of 3 FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 Injury Claim Card Below are tw o copies of your “ Injury Claim Card.” These cards contain all of the pertinent information that you w ill need to give to your Medical Providers so they can submit your medical bills to Liberty Mutual. The Claim Cards include your Claim number, Liberty Mutual' s mailing address and the telephone number for Medical Bill Provider Support. If your provider has any questions about a medical bill review , they can contact Provider Support directly. We encourage you to keep a copy of your Claim Card in your w allet to ensure that you have all of your claim information available at all times. Keep this card w ith you to provide billing information to your medical providers. Keep this card w ith you to provide billing information to your medical providers. Liberty Mutual Claim #: LA000-037777086-04 Liberty Mutual Claim #: LA000-037777086-04 Please send medical claim forms and records to: Please send medical claim forms and records to: PO Box 515097 PO Box 515097 Los Angeles, CA 90051-5097 Los Angeles, CA 90051-5097 For inquiries regarding a bill review : For inquiries regarding a bill review : Medical Bill Provider Support – Medical Bill Provider Support – 800-245-1700, Ext. 724-0286 800-245-1700, Ext. 724-0286 This card is for informational purpose only and is not a guarantee of payment. This card is for informational purpose only and is not a guarantee of payment. CWL2124 Page 1 of 1 FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW COVER LETTER LM General Insurance Company * Ronda Humphrey P.O. Box 515097 Tel: (800) 470-3811 Los Angeles, CA 90051-5097 DATE POLICYHOLDER POLICY NUMBER DATE OF ACCID CLAIM NUMBER 07/20/2018 Regina F. Milerson AOS-228-236650-40 07/05/2018 LA000-037777086-04 COMPLETE THE ATTACHED DB-450 FORM Keneon Thomas IMMEDIATELY IF YOU ARE ENTITLED TO NEW 14521 Tuskegee Airmen Way YORK STATE DISABILITY BENEFITS AND Jamaica NY 11435-5119 MAIL OR GIVE IT TO YOUR EMPLOYER. TO FIND OUT IF YOU ARE ELIGIBLE, TELEPHONE THE NEW YORK STATE DISABILITY BENEFITS BUREAU AT (718) 802 6964 Request. Dear Keneon Thomas: 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 Insurance Department; 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; c) 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 d) 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. NYS FORM NF-1A (Rev 1/2004)) NYSNF-1A FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 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 us if there is no such auto policy in your household. The above rule does not apply and you may file a No- Fault claim with us if you are the operator, owner or employee of the owner of the bus company. 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 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 ifit 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, Ronda Humphrey 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 1/2004) NYSNF-1A FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS LM General Insurance Company * Ronda Humphrey * P.O. Box 515097 Tel: (800) 470-3811 Los Angeles, CA 90051-5097 DATE POLICYHOLDER POLICY NUMBER DATE OF ACCID CLAIM NUMBER 07/20/2018 Regina F. Milerson AOS-228-236650-40 07/05/2018 LA000-037777086-04 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. Keneon Thomas * 14521 Tuskegee Airmen Way Jamaica NY 11435-5119 1. YOUR NAME 2. PHONE HOME BUSINESS NOS. 3. YOUR ADDRESS (NO., STREET, CITY OR TOWN AND ZIP CODE) 4. DATE OF BIRTH 5. SOCIAL SECURITY NO. 6. DATE AND TIME A.M. 7. PLACE OF ACCIDENT (STREET), CITY OR TOWN AND STATE OF ACCIDENT P.M. 8. BRIEF DESCRIPTION OF ACCIDENT: 9. DESCRIBE YOUR INJURY: 10. IDENTITY OF THE VEHICLE YOU OCCUPIED OR OPERATED AT THE 11. WERE YOU THE DRIVER OF THE TIME OF THE ACCIDENT: MOTOR VEHICLE? YES NO OWNER'S NAME MAKE YEAR WERE YOU A PASSENGER IN THE MOTOR VEHICLE? YES NO WERE YOU A PEDESTRIAN? YES NO THIS VEHICLE WAS: A BUS OR SCHOOL BUS WERE YOU A MEMBER OF OUR POLICYHOLDER'S HOUSEHOLD? YES NO A TRUCK, OR AN AUTOMOBILE DO YOU OR A RELATIVE WITH WHOM A MOTORCYCLE YOU RESIDE OWN A MOTOR VEHICLE? YES NO 12. WERE YOU TREATED BY A DOCTOR(S) OR OTHER PERSON(S) FURNISHIG HEALTH SERVICES? YES NO NAME AND ADDRESS OF SUCH DOCTOR(S) OR PERSON(S): 13. IF YOU WERE TREATED AT HOSPITAL(S), WERE YOU AN OUT-PATIENT? IN-PATIENT? DATE OF ADMISSION: HOSPITAL'S NAME AND ADDRESS: 14. AMOUNT OF HEALTH BILLS 15. WILL YOU HAVE MORE HEALTH 16. AT THE TIME OF YOUR ACCIDENT WERE YOU IN THE TO DATE TREATMENT(S)? COURSE OF YOUR EMPLOYMENT? $ YES NO YES NO 17. DID YOU LOSE TIME DATE ABSENCE FROM WORK BEGAN: HAVE YOU RETURNED IF YES, DATE RETURNED TO WORK: FROM WORK? TO WORK? YES NO YES NO AMOUNT OF TIME LOST FROM WORK: 18. WHAT ARE YOUR AVERAGE WEEKLY NUMBER OF DAYS YOU NUMBER OF HOURS YOU EARNINGS? WORK PER WEEK: WORK PER DAY: 19. WERE YOU RECEIVING UNEMPLOYMENT BENEFITS AT THE TIME OF THE ACCIDENT? YES NO CONTINUATION ON NEXT PAGE NYS FORM NF-2 NYSNF-2 FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 20. LIST NAMES AND ADDRESSES OF YOUR EMPLOYER AND OTHER EMPLOYERS FOR ONE YEAR PRIOR TO ACCIDENT DATE AND GIVE OCCUPATION AND DATES OF EMPLOYMENT: EMPLOYER NAME AND ADDRESS OCCUPATION FROM TO EMPLOYER NAME AND ADDRESS OCCUPATION FROM TO EMPLOYER NAME AND ADDRESS OCCUPATION FROM TO 21. AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES? YES NO 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: NEW YORK STATE DISABILITY? WORKERS' COMPENSATION? YES NO YES NO 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 RECOVERY PROVIDED FOR UNDER THE NO-FAULT LAW. THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE APPLICANT AS TRUE UNDER THE PENALTIES OF PERJURY "Any person who knowingly and with intent to defraud any insurance company or other person filesan 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." SIGNATURE: DATE: ............................................... DO NOT DETACH AUTHORIZATION FOR RELEASE OF WORK AND OTHER LOSS INFORMATION THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY WAGES, SALARY OR OTHER LOSS WHILE EMPLOYED BY YOU. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEWYORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW). NAME (PRINT OR TYPE) SOCIAL SECURITY NO. SIGNATURE DATE ............................................... DO NOT DETACH AUTHORIZATION FOR RELEASE OF HEALTH SERVICE OR TREATMENT INFORMATION THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED, X-RAYS AND PHYSICAL FINDINGS, DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW). NAME (PRINT OR TYPE) SIGNATURE DATE (IF THE APPLICANT IS A MINOR, PARENT OR GUARDIAN SHALL SIGN AND INDICATE CAPACITY AND RELATIONSHIP.) * BRACKETED LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER NYS FORM NF-2 NYSNF-2 FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 CLAIM NUMBER: LA000-037777086-04 NOTICE TO NO-FAULT BENEFITS APPLICANTS If you are eligible to receive New York State Disability Benefits as a result of this accident, you must advise us whether or not the New York State Disability Benefits you are eligible for are taxable. Whether or not your benefits are taxable will have an effect on the amount of benefits you may be eligible for under your Personal Injury Protection (No-Fault) loss of earnings benefits. The proof necessary to establish whether or not your New York State Disability Benefits are taxable can be one or more of the following: 1. A pay stub prior to the accident which shows you are not paying a premium for New York State Disability Benefits. 2. A check stub for New York State Disability Benefits received which shows taxes are withheld. 3. A W-2 form which reports Disability Benefits as income. 4. A copy of the completed DB-450 (Section C, from your employer) for this disability which indicates the percentage of disability premium paid by the employee. Please make sure that if you are claiming loss of earnings benefits under your Personal Injury Protection Coverage, we are provided with one or more of the items listed above. NYSNF-0 FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 VOLUNTARY NETWORK ACCESS PROGRAM Important Information Regarding Your Automobile Accident As part of our continuing effort to provide full service to our policyholders, Liberty Mutual has arranged to have a Voluntary Network Access Program available to assist you in finding the proper medical care. If you are injured in an automobile accident, you may be eligible to receive medical care through the Coventry Auto Network of facilities and providers. If you require medical care, you may contact the Coventry Auto Network Provider Locator Service at 1-800-330-9938. You will be assisted in locating a Coventry Auto Network provider near you. You may use the toll free number shown above to call for names of providers in your area between the hours of 9:00 AM and 5:00 PM, Monday through Friday. There is also a website you can access at www.coventrywcs.com. Click on 'CLIENT LOGIN & TOOLS'. In the Client Login in window enter Client ID ''lan''to locate a conveniently located medical provider. If you are interested in participating in the Voluntary Network Access Program, this is how the program works: Call the provider you choose, from those provided by Coventry Auto Network's Provider Locator Service, for an appointment and state that you are a Liberty Mutual policyholder and you have been in an auto accident. You will be given an appointment promptly. This provider will make all necessary referrals for testing and visits to other providers, after confirming benefits with a Liberty Mutual Claims Representative. Your personal injury benefits and the premium you pay on your policy will not change whether or not you select a voluntary medical provider or one of your own choice or any combination of the above. There will be no penalties imposed if you chose a provider who is not included in the Network. Liberty Mutual Insurance is pleased to offer this service to you. CWL2021-NY FILED: NEW YORK COUNTY CLERK 08/14/2020 03:06 PM INDEX NO. 654092/2019 NYSCEF DOC. NO. 38 RECEIVED NYSCEF: 08/14/2020 NOTICE AND PROOF OF CLAIM FOR DISABILITY BENEFITS CLAIMANT: READ THE FOLLOWING INSTRUCTIONS CAREFULLY 1. USE THIS FORM IF YOU BECOME SICK OR DISABLED WHILE EMPLOYED OR IF YOU BECOME SICK OR DISABLED WITHIN FOUR (4)WEEKS AFTER TERMINATION OF EMPLOYMENT. USE CLAIM FORM DB-300 IF YOU BECOME SICK OR DISABLED AFTER HAVING BEEN UNEMPLOYED MORE THAN FOUR (4) WEEKS. 2. YOU MUST COMPLETE ALL ITEMS OF PART A - THE " CLAIMANT'S STATEMENT." BE ACCURATE. CHECK ALL DATES. 3. BE SURE TO DATE AND SIGN YOUR CLAIM (SEE ITEM 12). IF YOU CANNOT SIGN THIS CLAIM FORM, YOUR REPRESENTATIVE MAY SIGN IT IN YOUR BEHALF. IN THAT EVENT, THE NAME, ADDRESS AND THE REPRESENTATIVE'S RELATIONSHIP TO YOU SHOULD BE NOTED UNDER THE SIGNATURE. 4. DO NOT MAIL THIS CLAIM UNLESS YOUR HEALTH CARE PROVIDER COMPLETES AND SIGNS PART B - THE "HEALTH CARE PROVIDER'S STATEMENT." 5. YOUR COMPLETED CLAIM SHOULD BE MAILED WITHIN THIRTY (30)DAYS AFTER YOU BECOME SICK OR DISABLED TO YOUR LAST EMPLOYER OR YOUR LAST EMPLOYER'S INSURANCE COMPANY . 6. MAKE A COPY OF THIS COMPLETED FORM FOR YOUR RECORDS BEFORE YOU SUBMIT IT. PART A - CLAIMANT'S STATEMENT (Please Print or Type) ANSWER ALL QUESTIONS 1. My name is First Middle Last Social Security Number 2. Address Number Street City or Town State Zip Code Apt. No. 3. Tel No. 4. Date of Birth / / 5. Married (Check one) Yes No 6. My disability is (If injury, also state how, when and where it occurred) 7. I became disabled on a. I worked on that day Yes No Mo. Day Year b. I have since worked for wages or profit Yes No If "Yes," give dates 8. Give name of last employer. If more than one employer during last eight (8) weeks, name all employers. EMPLOYERS DATES OF EMPLOYMENT AVERAGE WEEKLY WAGES BUSINESS BUSINESS TELEPHONE FROM THROUGH (Include Bonuses, Tips, Commissions, NAME ADDRESS NUMBER Mo. Day Year Mo. Day Year Reasonable Value of Board, Rent, etc.) 9. My job is or was Occupation Name of Union and Local No., if Member 10. For the period of disability covered by this claim a. Are you receiving wages, salary or separation pay: Yes No b. Are you receiving or claiming: (1) Workers' Compensation for work-connected disability Yes No