NEW YORK PERSONAL INJURY SUBROGATION ARBITRATION FORUM
Member Service Department
P. O. Box 30174
Tampa, FL 33630-3174
Phone: 1-866-977-3434
Overnight Mail:
3450 Buschwood Park Drive
Suite 250
Tampa, FL 33618
NY PIP-Form
This is mandatory Arbitration (Regulation 68, Section 65-4.11)
Check if Amendment (Highlight Amended Area)
Complete if you are a Third Party Administrator (TPA): TPA Code TPA Name
I. APPLICANT INFORMATION and ALLEGATIONS
NY PIP-Form 08/10 © 2011 Arbitration Forums, Inc.
Company Code Billing Code
Company/Subsidiary Name
Representative
Rep. Address
Telephone Number () ext.
Fax Number ()
E-Mail (Required)
Insured Name
File Number
Injured Party
Check Status Driver Occupant Pedestrian
Date of Loss
City State NY
LOCATION OF ACCIDENT (Must be in State of New York)
II. RESPONDENT INFORMATION and ALLEGATIONS
RESPONDENT # and COMPANY CODE
Total Company Claim Amount $
Payments Accepted $
I request One Year Deferment
Index Number Venue
I request Notice of Hearing
I request three-person panel
Appearance will be made by:
Company Representative Insured Expert Witness
CERTIFICATION OF SERVICE: I certify that a copy of this NY PIP-Form and Contentions Sheet is being simultaneously sent to each Respondent.
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Signature Date
NY PIP-Form 08/10 © 2011 Arbitration Forums, Inc.
RESPONDENT #1
Subsidiary Name
Rep. Name
Rep. Address
File #
Insured
RESPONDENT #2
Subsidiary Name
Rep. Name
Rep. Address
File #
Insured
RESPONDENT #3
Subsidiary Name
Rep. Name
Rep. Address
File #
Insured
Yes No A liability policy was in effect at the time of loss
Yes No Coverage has been denied for this claim
If yes, a copy of the denial letter to the party seeking coverage must be attached.
I admit % liability?
Amount Paid to Applicant Company: $
I request One Year Deferment
Index Number Venue
I request three-person panel
Appearance will be made by:
Company Representative Insured Expert Witness
COMPLETE THE FOLLOWING TO FILE A COUNTERCLAIM
Total Company Claim Amount $
Payments Accepted: $
Injured Party
Check Status Driver Occupant Pedestrian
CERTIFICATION OF SERVICE: I certify that a copy of this response is being simultaneously sent to all other parties.
______
Signature Date
Telephone Number () ext.
Fax Number ()
E-Mail (Required)
NY PIP-Form 08/10 © 2011 Arbitration Forums, Inc.
Arbitration Forums, Inc.
Contentions Sheet
(Required per Rules)
File provided by:(check one) Applicant or Respondent #
(Identify yourself below)
Company Name:
Insured: File #:
APPLICANT AFFIRMATIVE PLEADINGS:
RESPONDENT AFFIRMATIVE DEFENSES:
If you raise a Policy Limit affirmative defense, include the policy limit amount along with your affirmative defense description.
DEFERMENT JUSTIFICATION:
CONTENTIONS:
EVIDENCE:
List evidence which will support contentions stated above (i.e., police report, damages, estimates, statements). Photocopies of evidence are suggested. Photos will not be returned without a sufficient size self-addressed envelope with adequate postage. Note this request in the Administrative Request section below.
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APPLICANT ITEMIZED COMPANY-PAID DAMAGES:
Filing company: itemize payments made to support your Total Company Claim Amount. The Total Itemized Company-Paid Damages must match your Total Company Claim Amount.
Total Itemized Company-Paid Damages:
RESPONDENT DISPUTED DAMAGES:
Responding company (or applicant filing with automatic counter response): Present your damages arguments and outline the amount of damages in dispute. If left blank, damages will not be considered at issue.
Administrative Requests:
NY PIP-Form 08/10 © 2011 Arbitration Forums, Inc.