New York Codes, Rules and Regulations › Title 11 - INSURANCE › Chapter IX - Unfair Trade Practices › Part 216 - Unfair Claims Settlement Practices And Claim Cost Control Measures › Section 216.12 - Forms

Current through Register Vol. 46, No. 28, July 10, 2024
The forms in this section are hereby approved for use as
				  specified in this Part.
INSURER LETTERHEAD
NOTICE OF RIGHTS UNDER YOUR
PHYSICAL DAMAGE INSURANCE POLICY
INSURED ______
CLAIM # ______
POLICY # ______
DATE OF ACCIDENT__
Dear Insured:
We have been unable, after negotiating in good faith, to
				  reach an agreed price with you, your Designated Representative and/or your
				  repairer ______, the repairer of your choice. Pursuant
(
name of repair shop
)
				  ....................................................
to Insurance Regulation 64 of the New York State Department
				  of Financial Services, we are supplying you with the following information and
				  optional waiver.
Our offer of $ _ plus your deductible of $ _ and $ _ of
				  betterment or previous damage deduction is sufficient to repair your vehicle to
				  its pre-accident condition at a repair shop located reasonably convenient to
				  you. We are able to provide you with the identity of the repair shop that will
				  repair your vehicle at our estimate, but under the Insurance Law we may not
				  recommend a repairer unless you expressly request such information. Unless you
				  have already asked us to recommend a repair shop, you must sign the attached
Section 2610  of the Insurance Law Disclosure
				  Statement
in order to enable us to make such recommendation.
If your vehicle is repaired at a repair shop recommended by
				  us, the repair shop must issue a written guarantee that any work performed in
				  repairing your vehicle meets generally accepted standards for safe and proper
				  repairs. If our recommended repairer does not honor its written guarantee, we
				  will restore your vehicle to its pre-accident condition within a reasonable
				  time at no additional cost to you.
Your policy covers you for reasonable expenses that you incur
				  in order to protect your motor vehicle from further damage after a loss.
				  Contact us immediately for information as to what extent such expenses are
				  covered. NYS APD 1
INSURER LETTERHEAD
SECTION 2610  OF THE INSURANCE LAW
DISCLOSURE STATEMENT
Section 2610 of the New York State Insurance Law provides
				  that the insurance carrier shall not require that repairs be made in a
				  particular place or shop or by a particular concern.
The Law further provides that the Insurance Company shall not
				  recommend or suggest repairs be made in a particular place or shop or by a
				  particular concern, unless expressly requested by you.
I acknowledge receipt of a copy of this notice.
DATE
SIGNATURE INSURED/VEHICLE OWNER
.........................................................................................................
I have read the above notice and understand the Insurance
				  Company cannot require or recommend that repairs be made in a particular place
				  or by a particular person unless I expressly request such recommendation. I
				  hereby, of my own volition, request that the Insurance Company or its
				  representative recommend a repair shop.
DATE
..
SIGNATURE INSURED/VEHICLE
				  OWNER
.........................................................................................................
NYS APD 1-a
CERTIFICATION OF AUTOMOBILE REPAIR
.........................................................................................................
(TO BE COMPLETED BY INSURER)
INSERT:
.........................................................................................................
INSURED
.........................................................................................................
INSURER'S NAME
.........................................................................................................
CLAIM #
.........................................................................................................
INSURER'S ADDRESS
.........................................................................................................
POLICY #
DATE OF ACCIDENT
DEDUCTIBLE $
.........................................................................................................
Section 3411 (i) of the NEW YORK INSURANCE LAW (NYIL) and
				  Article 12-A of the Vehicle and Traffic Law (V&TL) require that the
				  following certification be completed and signed by both the insured and the
				  automobile repairer. These laws also require submission of the repair invoice
				  (Paid Bill) by the automobile repairer or the insured to the insurer whenever
				  any repairs are made. The NYIL does not require an insured to repair the
				  automobile as a condition of payment of a loss. This form must be completed and
				  returned to the insurer within 45 days. A postage-paid return envelope has been
				  furnished for your convenience.
ANY PERSON WHO, 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 FRAUD ULENT 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.
PART I
TO BE COMPLETED BY THE INSURED:
I, __ certify, under penalties of perjury, that:
(
print your name
)
Check A or B
_ A. I have not made any repairs to my automobile as a result
				  of this loss.
_ B. I have made repairs to my automobile and I have attached
				  a copy of my invoice for repairs to my automobile as a result of the captioned
				  loss.
IMPORTANT NOTICE TO INSURED
IF THIS CERTIFICATION IS NOT COMPLETED AND RETURNED, TOGETHER
				  WITH A COPY OF THE ITEMIZED PAID BILL, IT WILL BE ASSUMED THAT YOU DID NOT
				  REPAIR YOUR MOTOR VEHICLE. IF YOU HAVE A SUBSEQUENT LOSS, THE COMPANY MUST, TO
				  THE EXTENT RELEVANT, DEDUCT SUCH UNREPAIRED ITEMS AS PREVIOUS DAMAGE IN
				  SETTLING A FUTURE LOSS. IF YOU DO NOT REPAIR ALL THE DAMAGES ALLOWED BY THE
				  INSURER, SUCH REPAIRS NOT PERFORMED MAY REDUCE YOUR SETTLEMENT OF ANY FUTURE
				  LOSS. THEREFORE, IF AFTER SIGNING THIS CERTIFICATION, YOU REPAIR ANY DAMAGE
				  CAUSED BY THIS ACCIDENT, YOU SHOULD NOTIFY THE COMPANY IMMEDIATELY. THE COMPANY
				  MAY AT THAT TIME ELECT TO INSPECT YOUR AUTOMOBILE.
DATE
SIGNATURE OF INSURED
PART II
TO BE COMPLETED BY THE AUTOMOBILE
				  REPAIRER:
I, (
print your name
) owner or officer of
				  (
print name of auto repair
) shop
Auto Repair Shop Registration Number __ _, located at ______
				  certify, under penalties of perjury, that I have made the repairs to the
				  automobile owned by (
print name of insured
),
as shown on the attached itemized invoice. I further certify
				  that:
Check A or B
_ A. I have repaired all the items allowed by the insurer,
				  or, if not,
_ B. I have repaired the automobile as described on the
				  attached itemized invoice.
DATE
SIGNATURE OF REPAIRER
........................................................................................................
(
Owner or Officer
)
NYS APD 2