Helpful Forms
Helpful Forms
Whether you are looking for a no fault insurance form or are in need of a disability benefits form, Basch & Keegan LLC, has you covered. If you don't see a form that you are in need of, please contact us so we can further assist you.
Click on The Document Name Below to View or Download a Form
No Fault Forms
- Request For No-Fault Mileage Reimbursement (PDF)
- Request For No-Fault Reimbursement of Household Services (PDF)
- NF-1A – No Fault Cover Letter (PDF)
- NF-2 – Application For NY Motor Vehicle No-Fault Benefits (PDF)
- NF-6 – Employer’s Wage Verification Report Form (PDF)
- NF-7 – NY Motor Vehicle No-Fault Insurance Law Verification of Self-Employment Form (PDF)
- NF-8 – Agreement To Pursue Social Security Disability Benefits (PDF)
- NF-11– Additional PIP Sub Agreement (PDF)
Motor Vehicle Forms
Miscellaneous Forms
- DB-450 – Notice and Proof of Claim For Disability Benefits (PDF)
- SSA-3288 – Social Security Consent for Release of Information (PDF)
- CMS-10106 – Medicare Authorization To Disclose Personal Health Information (PDF)
- Medicare Proof of Representation (PDF)
- DOH-5198 – Authorization To Release Protected Medicaid Member Information To a Third Party (PDF)
- 4506 – Request For Copy of Tax Return (PDF)
- SF95-07a – Claim For Damage, Injury or Death Form (PDF)
- DB300 - Notice and Proof of Claim (PDF)
- HIPAA - Authorization For Release Of Health Information Pursuant To HIPAA (PDF)
Office Forms
- Before Your First Visit: Check List (Call Our Office)
- What To Expect During Your IME (Call Our Office)
- Form 960 – Authorization For Release Of Health Information Pursuant To HIPPA (PDF)
- NYS SUM / UM Demand for Arbitration (PDF)
- New York Motor Vehicle No-Fault Insurance Law Arbitration Request Form (PDF)
- Complaints about New York State Hospitals and Diagnostic and Treatment Centers (Link to Off-Site Contact Form)
- DOH-3867 – Office of Professional Medical Conduct Doctor Complaint Form
- Retainer Agreement - Retainer For Legal Services (PDF)
The Opinons that matter Most
Serious injuries require genuine representation-
John was quick to respond, helpful and honest
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John was quick to respond, helpful and honest regarding my situation and the questions I had. Also easy to talk to which is always appreciated!
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Strong and Persistent
“Strong and Persistent”
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Best of the best of the best!
“Compassionate, dedicated, professional...Eli, Maureen, Derek, John, and all the staff.”
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Professional, Responsive & Communicative
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Maureen and her crew do one heck of a job!!!!
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Extremely responsive, even after hours!
“Highly recommended!”
What sets us apart?
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We Understand How You FeelWe recognize the difficulty that injury victims face. Let us take some of the weight off your shoulders.
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Personalized & Passionate RepresentationWe consistently obtain excellent results because our opponents know we don’t back down. We are ready to fight for you.
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A History of SuccessWe’ve recovered tens of millions of dollars in compensation for personal injury victims in the Hudson Valley. Ask your friends and neighbors about us.
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For Us, Every Case Is PersonalOur attorneys spend significant time with each and every client, explaining the legal process and ensuring that our clients understand their options at every stage of their case.
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Proven Strategy for Getting Exceptional SettlementsWe work hard for our clients and prepare each case for trial. This proven strategy enables us to obtain higher settlement values on behalf of our clients.