To submit this form, ensure it is completed and signed in all necessary sections. Provide any additional documentation as required, such as medical records or wage statements. Submit the form to your insurance company's claims department using their provided submission method, which can include email, fax, online submission forms, or physical mail. For email, use the claims department’s email address; for fax, use their provided fax number; for online submission, follow the instructions on the insurance company's website; for physical mail, use the provided mailing address. For best results, contact your insurance company for specific instructions and use certified mail or request a receipt confirmation.

Ensure you submit the form promptly after your accident to be eligible for benefits. For claims in 2024 and 2025, submit the form as soon as possible after the accident incurred to ensure timely processing.

The purpose of this form is to allow individuals to apply for benefits under the Minnesota No-Fault Automobile Insurance Act. This form ensures that all necessary information is documented, including personal details, accident specifics, medical information, and financial expenses, so that eligibility for benefits can be accurately assessed. Both policyholders and medical providers need to complete and submit this form to process claims and provide required information.

• 1. Applicant's Name: The full legal name of the person applying for benefits.
• 2. Phone: Home and business phone numbers of the applicant.
• 3. Address: The applicant's full address including street, city, state, and ZIP code.
• 4. Date of Birth: The applicant’s date of birth.
• 5. Social Security No.: The applicant's Social Security Number.
• 6. Date and Time of Accident: The exact date and time when the accident occurred.
• 7. Place of Accident: Details of the accident location including street, city, town, and state.
• 8. Brief Description of Accident: A short description of how the accident happened.
• 9. Owner of Vehicle: The name of the vehicle's owner involved in the accident.
• 10. Type, Year, License Plate No.: Details of the vehicle including type, year, and license plate number.
• 11. Describe Automobiles Owned: Information about other automobiles owned by the applicant or family members residing in the same household.
• 12. Automobile Owner: The name of the automobile owner.
• 13. Insurer: The name of the insurer.
• 14. Policy Number: The insurance policy number.
• 15. Injured?: Indicate if the applicant was injured in the accident.
• 16. Signature: The applicant’s signature.
• 17. Date: The date when the form was signed.
• 18. Describe Your Injury: Details about the injuries sustained in the accident.
• 19. Treated by a Doctor?: Indicate if the applicant was treated by a doctor and provide the doctor’s contact details.
• 20. Hospital Name and Address: Name and address of the hospital where the applicant was treated, if applicable.
• 21. Amount of Medical Bills: The amount of medical bills incurred to date.
• 22. Further Medical Expense?: Indicate if further medical expenses are expected.
• 23. In Course of Employment?: Whether the accident occurred during the applicant's course of employment.
• 24. Date Disability Began: The date when the disability caused by the accident began.
• 25. Date Returned to Work: The date when the applicant returned to work.
• 26. Gross Weekly Wage or Salary: The applicant's gross weekly wage or salary.
• 27. Received Workmen’s Compensation?: Indicate if the applicant has received or is eligible for worker’s compensation benefits.
• 28. Employer and Address: Details of the applicant’s current employers, including their addresses.
• 29. Occupation: The applicant’s occupation.
• 30. From, To: Employment dates for current employers.
• 31. Other Expenses?: Indicate if the applicant has had any other expenses as a result of the injury and provide details.
• 32. Signature of Applicant or Parent or Guardian: Signature of the applicant, or their parent or guardian if the applicant is a minor.
• 33. Authorization for Medical Information: Signature section to authorize the release of medical information.
• 34. Authorization for Wage and Salary Information: Signature section to authorize the release of wage and salary information.
• 35. Claim Number: The claim number assigned to the application.
• 36. Claim Representative: The name of the claim representative handling the application.
• 37. Authorization for Release of Information: Signature section to authorize the release of all other necessary information.

Failing to submit this form may result in a delay or denial of benefits under the Minnesota No-Fault Automobile Insurance Act. It is important to complete and return the form promptly to ensure your claim is processed in a timely manner.

• Delay in Benefits: Not submitting the form on time can delay the processing of your benefits.
• Denial of Benefits: Failure to provide required information might lead to a denial of your benefits claim.
• Incomplete Documentation: Without the completed form, your claim may be considered incomplete, leading to further complications.

• 1. Automobile Accident: To report and claim benefits after an automobile accident.
• 2. Medical Treatment and Expenses: To document medical treatment received and expenses incurred due to the accident.
• 3. Employment Information: To provide employment details and authorize the release of wage information.
• 4. Injury Details: To describe the injuries sustained in the accident.
• 5. Authorization for Information Release: To authorize the release of medical and other relevant information needed for the claim.