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
- Personal Injury Intake Form
- 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)
What Sets Us Apart?
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Here to Help Win the Fight
With our proven experience, we're known for tackling tough claims. If you or a loved one has been harmed by someone else's negligence, we're here to help you fight for justice.
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Here to Help Get Results
We have the resources and experience to help victims level the playing field with even the most powerful adversaries – and we have the record of success to back it up.
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Here to Help When You’re Hurt
We provide reliable support, allowing you to focus on recovery while we handle your legal claim.
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Here to Help Regardless of Who You Ask
Our focus on personal attention lets us craft legal strategies tailored to each client's unique needs, earning us the respect of our peers.
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Here to Help The Community
Our lawyers have deep roots in the community and a lengthy history of giving back. When the community needs us, we are always here to help.