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)
Client Testimonials
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Genuinely concerned and dedicated.
“I was severely injured in a head-on accident. Basch & Keegan LLP handled my case over the past 3.5 years and I highly recommend them. The team genuinely understood my TBI, took the time to listen, and showed how it truly impacts my daily life. They kept in regular contact, always answered questions, and showed genuine concern for me and my family. The outcome was successful because of their dedication and hard work. This firm fights for you and gets results! We cannot recommend them enough.”
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Extremely helpful and informative.
“Came to Basch & Keegan LLP in 2019 with a slip-and-fall case. Everyone was extremely helpful and informative through every step. Very happy with the outcome of my case. Highly recommend this amazing firm!”
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Treated me like family.
“When you get hurt, call Basch & Keegan LLP. They truly are the best in every way. The attorneys are graceful and powerful in the courtroom and treated me like family. They secured more and more money over a 7-year period with more on the way. Highly recommended!”
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This firm will fight for you and get results! We cannot recommend them enough!
“Above everything, John and Katie showed genuine concern for me and my family. It’s clear how passionate John is about his work and doing what’s best for his clients.”
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I will certainly recommend Maureen Keegan in the future!
“Throughout the 2+ years, Maureen Keegan continued to persevere on my behalf, contacting doctors, etc. and continually informing me of the status of my case.”
What sets us apart?
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Here to Help Win the Fight
Backed by our experience and insight, we’ve become known for taking on the toughest claims. If you or someone you love has been injured by the negligence or wrongful acts of another, we’re here to help you fight for the justice you deserve.
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HERE TO HELP Get Results
At Basch & Keegan LLP, 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 serve as the support system you can rely on as you begin your recovery. We go the extra mile to ensure you can focus on getting better while we work on the legal aspects of your claim.
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HERE TO HELP Regardless of Who You Ask
We place an emphasis on personal attention. This approach allows us to create legal strategies custom-tailored to each client’s unique circumstances and has earned us the respect of our peers.
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HERE TO HELP The Community
Our Kingston-based lawyers have deep roots in the community and a lengthy history of giving back to Ulster County. When the community needs us, we are always here to help.