General Insurance Claims Forms
HIPAA: Authorizes medical providers to share information with Preferred Mutual about medical care you receive that is related to a claim with us.

Lightning Affidavit: Document completed by a service technician to verify the cause of loss to a claimed electronic device.

Statement of Loss: Give complete descriptions of all property that is included in your claim (year/make/model, serial #, receipts, estimates for repair/replacement, etc).

Policyholder Notice of Theft: Document for the insured to describe the details of their loss and list their claimed items.

Medicare SCHIP: The form required to determine Medicare eligibility.

Proof of Ownership Guidelines: Explains the various ways an insured can prove ownership of claimed items.

Statement Form: Form used by the insured party to describe the facts, circumstances and details of their loss.

Insured Statement of Automobile Loss: Form for the insured to document the details of their motor vehicle accident.
Massachusetts Claims Forms
MA - Affidavit of Insurance 
Form used in applying for Massachusetts No-Fault benefits to specify an individual’s health insurance.

MA - Application for Benefits
Form used to apply for Massachusetts No-Fault benefits.

MA - Crash Report
Form for the insured to document the details of their accident.
New Jersey Claims Forms
NJ - Application for Benefits
Form used to apply for New Jersey No-Fault benefits.
New York Claims Forms
NY - Report of Motor Vehicle Accident (NYS MV104A)
Accident report form that needs to be sent to the DMV for accidents with injuries or property damage over $1,000.

NY - Application for No-Fault Benefits (NF-2)
Form used to apply for New York No-Fault benefits.

NY - Application for Additional PIP Subrogation (NF-11)
New York No-Fault form used to allow Preferred Mutual to pursue reimbursement from the at fault party.

NY - Verification of Self Employment Income (NF-7)
Verification of self-employment income for New York No-Fault claims.

NY - Application for Optional Benefits Election (NF13)
New York No-Fault form used for the insured to select the allocation of OBEL benefits.

NY - Auto No-Fault Cover Letter
Explanation of New York No-Fault benefits (accompanies NY - Application for Benefits (Form NF-2)).

NY - Employer Wage Verification Report (NF-6)
New York No-Fault form used to verify income for No-Fault claims.

NY - Assignment of Benefits (AOB)
New York No-Fault form used by a claimant to allow Preferred Mutual to pay a medical provider directly.

NY - Social Security Benefits Form (NF-8)
New York No-Fault form used to confirm a claimant will apply for Social Security Disability benefits.

NY - Claim for Disability Benefits (DB-450)
Form for an injured claimant to complete for New York State Disability insurance. 

EIP Mileage Form NY
Form used to document a claim for mileage reimbursement under New York No-Fault.

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