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No-Fault Motor Vehicle Accident Application

PATIENT NO-FAULT APPLICATION | ENGLISH

Please complete the application below or call 866.621.3601 for assistance.

Residents of no-fault states are required to carry medical coverage on their automobile insurance. Your automobile insurer requests that a no-fault application be submitted to determine if you are entitled to benefits under your state’s No-Fault Motor Vehicle Insurance Act. We will submit it promptly to your auto insurance carrier.