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 Opinions that matter Most
Serious injuries require genuine representation-
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.”
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Derek was extremely helpful and informative through every step of the way.
“Everyone in the firm was pleasant. Thank you for helping to achieve this victorious win! I highly recommend this amazing firm!”
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Your first mistake would be not to call Basch & Keegan because they truly are the very best in every way.
“All of the attorneys treated me like family which is very important when you are injured. Derek Spada has become my personal friend and holds a special place in my heart forever.”
What sets us apart?
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100+ Years of Combined Legal ExperienceOur team's experience in personal injury law will benefit your case. We have settled more than 10,000 cases for our clients.
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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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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.
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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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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.