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PLEASE COMPLETE AND SUBMIT THIS FORM TO OUR CLAIMS REPRESENTATIVE AS SOON AS POSSIBLE. PLEASE NOTE COMPLETED FORM MUST BE SUBMITTED TO INSURER NO LATER THAN 90 DAYS AFTER WORK LOSS WAS FIRST INCURRED Thank you for your cooperation. EMPLOYEE S OCCUPATION DATES OF EMPLOYMENT GROSS EARNINGS DURING 52 WEEK PERIOD PRIOR TO ACCIDENT WAGE OR SALARY AS OF DATE OF ACCIDENT FROM THROUGH HOURLY WEEKLY MONTHLY NUMBER OF HOURS NORMALLY WORKED PER DAY NUMBER OF DAYS NORMALLY WORKED PER WEEK DATES ABSENT...
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Comments and Help with nys wage verification form

Who needs the NF-6 form?

The NF-6 form is the New York State form, the full name of which is the New York Motor Vehicle No-Fault Insurance Law Employer’s Wage Verification Report. The form should be filled out by the employer whose employee has filed an application for benefits as a result of injuries received in a motor vehicle accident according to the provisions of the New York Motor Vehicle Insurance Reparations Act (No-Fault Law).

What is the purpose of the NYS Form NF-6?

The information the form requests is important in order to help the insurer determine the claimant’s eligibility for the benefits due after the motor vehicle accident.

When is the NF-6 form due?

It is requested that the form should be returned to the insurer within 90 days after work loss was first incurred.

Is the NYS Form NF-6 accompanied by any other forms?

The Employer’s Wage Verification Report does not have to be accompanied by any other forms. However, if the situation requires attaching some additional documents, the employer will be notified about it.

How to fill out the NYS Form NF-6?

The New York Motor Vehicle No-Fault Insurance Law Employer’s Wage Verification Report must cover the following information on the insurer’s part:

  • Name and address;

  • Details about the insurer’s claim representative;

  • Date of filing;

  • Policyholder;

  • Policy number;

  • Date of accident;

  • Claim number;

  • Details about the employee who made a claim;

  • Employer’s name and address.

The employer is required to provide the following details about the employee:

  • Occupation;

  • Employment dates;

  • Gross earnings;

  • Dates of absence from work;

  • Eligibility for Workers’ Compensation Law or NYS Disability Benefits;

  • Any reimbursement the employee is entitled to, etc.

Where do I send the filled out NF-6?

The employer should return the completed NYS Employer’s Wage Verification Report to the insurer who requested the document.