Fill and Sign the Oklahoma Durable Power of Attorney Effective Immediately Form

NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS NAME, ADDRESS, AND PHONE NUMBER OF INSURER'S NAME, ADDRESS, AND PHONE NUMBER OF INSURER’S CLAIMS REPRESENTATIVE* CLAIMS REPRESENTATIVE* NAME AND ADDRESS OF INSURER* NAME AND ADDRESS OF INSURER * DATE POLICYHOLDER POLICY NUMBER DATE OF ACCIDENT CLAIM NUMBER TO ENABLE US TO DETERMINE IF YOUR ARE ENTITLED TO BENEFITS UNDER THE NEW YORK NO-FAULT LAW, PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY. IMPORTANT: 1. TO BE ELIGIBLE FOR BENEFITS YOU MUST COMPLETE AND SIGN THIS APPLICATION. 2. YOU MUST SIGN ANY ATTACHED AUTHORIZATION(S). 3. RETURN PROMPTLY WITH COPIES OF ANY BILLS YOU HAVE RECEIVED TO DATE. NAME AND ADDRESS OF APPLICANT* NAME AND ADDRESS OF APPLICANT* 1. YOUR NAME 2. PHONE NOS. 6. DATE AND TIME OF ACCIDENT BUSINESS 4. DATE OF BIRTH 3. YOUR ADDRESS (NO., STREET, CITY OR TOWN AND ZIP CODE) HOME 5. SOCIAL SECURITY NO. 7. PLACE OF ACCIDENT (STREET), CITY OR TOWN AND STATE A.M. P.M. 8. BRIEF DESCRIPTION OF ACCIDENT 9. DESCRIBE YOUR INJURY 10. IDENTITY OF VEHICLE YOU OCCUPIED OR OPERATED AT THE TIME OF THE ACCIDENT: OWNER'S NAME THIS VEHICLE WAS: MAKE YEAR A BUS OR SCHOOL BUS, OR A MOTORCYCLE A TRUCK, AN AUTOMOBILE, YES 11. WERE YOU THE DRIVER OF THE MOTOR VEHICLE? WERE YOU A PASSENGER IN THE MOTOR VEHICLE? WERE YOU A PEDESTRIAN? WERE YOU A MEMBER OF OUR POLICYHOLDER’S HOUSEHOLD? DO YOU OR A RELATIVE WITH WHOM YOU RESIDE OWN A MOTOR VEHICLE? CONTINUATION ON NEXT PAGE NYS FORM NF-2 (Rev 1/2004) Page 1 of 3 NO APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS - - PAGE TWO 12. WERE YOU TREATED BY A DOCTOR(S) OR OTHER PERSON(S) FURNISHING HEALTH SERVICES? YES NO IF YES, NAME AND ADDRESS OF SUCH DOCTOR(S) OR PERSON(S): 13. IF YOUR WERE TREATED AT A HOSPITAL(S), WERE YOU AN OUT-PATIENT? IN-PATIENT? DATE OF ADMISSION: HOSPITAL'S NAME AND ADDRESS: 14. AMOUNT OF HEALTH BILLS TO DATE: 15. WILL YOU HAVE MORE HEALTH TREATMENT(S)? YES NO $ 17. DID YOU LOSE TIME FROM WORK? YES NO DATE ABSENCE FROM WORK BEGAN: IF YES, DATE RETURNED TO WORK: 18. WHAT ARE YOUR GROSS AVERAGE WEEKLY EARNINGS? 16. AT THE TIME OF YOUR ACCIDENT WERE YOU IN THE COURSE OF YOUR EMPLOYMENT? YES NO HAVE YOU RETURNED TO WORK? YES NO AMOUNT OF TIME LOST FROM WORK: NUMBER OF DAYS YOU WORK PER WEEK: NUMBER OF HOURS YOU WORK PER DAY: 19. WERE YOU RECEIVING UNEMPLOYMENT BENEFITS AT THE TIME OF THE ACCIDENT? YES NO 20. LIST NAMES AND ADDRESS OF YOUR EMPLOYER AND OTHER EMPLOYERS FOR ONE YEAR PRIOR TO ACCIDENT DATE AND GIVE OCCUPATION AND DATES OF EMPLOYMENT: EMPLOYER AND ADDRESS OCCUPATION FROM TO EMPLOYER AND ADDRESS OCCUPATION FROM TO EMPLOYER AND ADDRESS OCCUPATION FROM TO 21. AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES? YES NO IF YES, ATTACH EXPLANATION AND AMOUNTS OF SUCH EXPENSES. 22. DUE TO THIS ACCIDENT HAVE YOU RECEIVED OR ARE YOU ELIGIBLE FOR PAYMENTS UNDER ANY OF THE FOLLOWING: YES NO NEW YORK STATE DISABILITY? WORKERS' COMPENSATION? CONTINUATION ON NEXT PAGE NYS FORM NF-2 (Rev 1/2004) Page 2 of 3 APPLICATION FOR MOTOR VEHICLE NO-FAULT BENEFITS - - PAGE THREE THE APPLICANT AUTHORIZES THE INSURER TO SUBMIT ANY AND ALL OF THESE FORMS TO ANOTHER PARTY OR INSURER IF SUCH IS NECESSARY TO PERFECT ITS RIGHTS OF RECOVERY PROVIDED FOR UNDER THE NO-FAULT LAW. THIS FORM IS SUBSCRIBED AND AFFIRMED BY THE APPLICANT AS TRUE UNDER THE PENALTIES OF PERJURY ANY PERSON WHO KNOWINGLY AND WITH INTENT TO DEFRAUD ANY INSURANCE COMPANY OR OTHER PERSON FILES AN APPLICATION FOR COMMERCIAL INSURANCE OR A STATEMENT OF CLAIM FOR ANY COMMERCIAL OR PERSONAL INSURANCE BENEFITS CONTAINING ANY MATERIALLY FALSE INFORMATION, OR CONCEALS FOR THE PURPOSE OF MISLEADING, INFORMATION CONCERNING ANY FACT MATERIAL THERETO, AND ANY PERSON WHO, IN CONNECTION WITH SUCH APPLICATION OR CLAIM, KNOWINGLY MAKES OR KNOWINGLY ASSISTS, ABETS, SOLICITS OR CONSPIRES WITH ANOTHER TO MAKE A FALSE REPORT OF THE THEFT, DESTRUCTION, DAMAGE OR CONVERSION OF ANY MOTOR VEHICLE TO A LAW ENFORCEMENT AGENCY, THE DEPARTMENT OF MOTOR VEHICLES OR AN INSURANCE COMPANY, COMMITS A FRAUDULENT INSURANCE ACT, WHICH IS A CRIME, AND SHALL ALSO BE SUBJECT TO A CIVIL PENALTY NOT TO EXCEED FIVE THOUSAND DOLLARS AND THE VALUE OF THE SUBJECT MOTOR VEHICLE OR STATED CLAIM FOR EACH VIOLATION. SIGNATURE DATE DO NOT DETACH AUTHORIZATION FOR RELEASE OF WORK AND OTHER LOSS INFORMATION THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY WAGES, SALARY OR OTHER LOSS WHILE EMPLOYED BY YOU. YOUR ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW). NAME (PRINT OR TYPE) SOCIAL SECURITY NO. SIGNATURE DATE DO NOT DETACH AUTHORIZATION FOR RELEASE OF HEALTH SERVICE OR TREATMENT INFORMATION THIS AUTHORIZATION OR PHOTOCOPY THEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED, X-RAYS AND PHYSICAL FINDINGS, DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE NEW YORK COMPREHENSIVE MOTOR VEHICLE INSURANCE REPARATIONS ACT (NO-FAULT LAW). NAME (PRINT OR TYPE) SIGNATURE DATE (IF THE APPLICANT IS A MINOR, PARENT OR GUARDIAN SHALL SIGN AND INDICATE CAPACITY AND RELATIONSHIP). *LANGUAGE TO BE FILLED IN BY INSURER OR SELF-INSURER. NYS FORM NF-2 (Rev 1/2004) Page 3 of 3