DATE
DEAR APPLICANT:
This three
part form must be completed by you and your district Social Security office in order for your No-Fault
loss of earnings benefits to continue without interruption.
I agree to apply for and diligently pursue within 35 days from the date above,
Social Security Disability benefits that may be recoverable on account of injuries caused by this accident.
The applicant further agrees to reimburse the Insurer for any amounts that may have been or may be advanced
by the Insurer pursuant to this agreement, pending receipt of Social Security Disability benefits. The applicant may deduct
from the reimbursement any attorney's fee which he/she paid in order to obtain the Social Security Disability benefits.
(NAME OF INSURER OR SELF-INSURER), upon receipt of this agreement and the Authorization for Release
of Information by the Social Security Administration, both duly signed by the Applicant or the Applicant's legal guardian,
agrees to continue the payment of No-Fault benefits for loss of earnings without deducting amounts recoverable as Social
Security Disability benefits as permitted by Section 5102(b)(2) of the New York Insurance Law, until such Social Security
Disability benefits are received.
In the event that the applicant fails to sign and return this Agreement and Authorization or to apply for Social
Security Disability benefits in accordance with this Agreement within the aforesaid 35 day period, the insurer shall
estimate the amount of monthly Social Security Disability benefits which it believes the applicant would be entitled to
receive and, beginning with the seventh month from the date of accident or 35 calendar days after the agreement was
forwarded to the applicant, in the event the seventh month has passed, the insurer shall deduct the estimated Social
Security Disability benefits from loss of earnings benefits due on account of injuries caused by this accident to the applicant.
*LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER.
NYS FORM NF-8 (Rev 1/2004)
Page 1 of 2
SIGNATURE OF INSURER'S REPRESENTATIVE
DATE
DATE
NAME AND ADDRESS OF APPLICANT*
(NAME OF APPLICANT)
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.
SIGNATURE OF APPLICANT
POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER
NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW
AGREEMENT TO PURSUE SOCIAL SECURITY DISABILITY BENEFITS
NAME AND ADDRESS OF INSURER OR SELF-
INSURER*
NAME, ADDRESS, AND PHONE NUMBER OF
INSURER’S CLAIMS REPRESENTATIVE*