100 William St, 14th Floor, New York, NY 10038

Insurance Forms

INSURANCE FORMS

Notice of Intention (NOI) - PDF version

Household Affidavit (HHA) – PDF version

Click on any of the above forms to either download or print. 

 ** Please be advised that the Notice of Intention (NOI) and Household Affidavit (HHA) must be signed by the individual (or Legal Guardian) applying for the benefits and be properly notarized when submitted to MVAIC.  The receipt of any incomplete documents could affect the eligibility for MVAIC benefits.

 

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.

Glossary

WORK LOSS

Available for up to a maximum payment of $2,000 per month for a maximum period of three years from...


UNINSURED MOTOR VEHICLE

A motor vehicle other than a motor vehicle described in subsection (c) hereof...


REGULATION 68

New York State Rules and Regulations that govern No-Fault coverage.  See Regulation 68 for...


QUALIFIED PERSON

(i) a resident of this state, other than an insured or the owner of an uninsured motor vehicle and...

Learn More Terms

About MVAIC

Annual Reports

MVAIC Annual Reports are available in the About MVAIC section. Click below to learn more.

History

MVAIC was created in 1958 by the New York State Legislature by enactment of Article 17-A (now Article 52) of the New York Insurance Law.  MVAIC operates as a non-profit organization, and provides No-Fault and Bodily Injury coverage to those claimants that are eligible for benefits. (Refer to Article 52 of the New York State Insurance Law for specifics)

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Contact Us

You can contact us via regular mail or by phone:

100 William Street 14th Floor
New York, New York 10038

(646) 205-7800

 

You can also contact us via email. Please provide us with your contact information, your claim number (if applicable) and your reason for inquiry, and you will receive a prompt response.

If you have any general or claim related questions, please contact us at .

If you have a complaint that you would like to address directly with us, please contact us at .

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