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Nf6 Form 2004-2023
SOCIAL
SECURITY NO.
NAME AND ADDRESS OF EMPLOYER*
DEAR EMPLOYER:
The above named person has applied for benefits under the NEW YORK COMPREHENSIVE MOTOR VEHICLE
INSURANCE REPARATIONS ACT (NO-FAULT LAW) as a result of injuries sustained in a motor vehicle accident on the
date indicated. We understand this person is your employee or former employee. To assist us in determining benefits
that may be due the applicant, please provide us with the answer to the following questions.
PLEASE COMPLETE...
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