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
- 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)
- 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)
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.”
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.”
Helpful & Honest
“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!”
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!”
Extremely helpful law firm and staff
“Extremely helpful law firm and staff...John and his staff nothing but the best.”
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.
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.
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.
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.
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.