New York No-Fault Arbitration

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. The undersigned affirms and certifies as true under the penalty of perjury that this filing is being made in good faith and that upon information, belief and reasonable inquiry the documents being submitted herewith are not fraudulent and that exact copies of all documents provided herewith have been mailed to the insurer against whom the arbitration is being requested. Unless disclosed with this submission, the disputed amounts remain unpaid to the applicant by any payor and there has been no other filing of an arbitration request or lawsuit to resolve the disputed matters contained in this submission. 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. The undersigned affirms and certifies as true under the penalty of perjury that this filing is being made in good faith and that upon information, belief and reasonable inquiry the documents being submitted herewith are not fraudulent and that exact copies of all documents provided herewith have been mailed to the insurer against whom the arbitration is being requested. Unless disclosed with this submission, the disputed amounts remain unpaid to the applicant by any payor and there has been no other filing of an arbitration request or lawsuit to resolve the disputed matters contained in this submission.