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NEW YORK MOTOR VEHICLE NO-FAULT INSURANCE LAW VERIFICATION OF SELF-EMPLOYMENT INCOME NAME AND ADDRESS OF INSURER OR SELF-INSURER* NAME AND ADDRESS OF INSURER OR REINSURER* POLICYHOLDER NAME, ADDRESS,
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Only for the purpose of determining your eligibility for the optional supplemental insurance policy that may be offered as the result of a claim. Your identification will not be disclosed to anyone. If you do not know your claim information, do not submit it. If you provide the requested information to one of our agents, we will process your claim on our own, without any outside assistance. The identity of the driver of a vehicle involved in an accident is confidential information, subject to change without notice. The requested information is solely for the purpose of the identification process for the supplemental insurance policy that may be offered as the result of a claim. It is not a guarantee of coverage and does not indicate whether you are entitled to financial support by the INSURANCE COMPANY. INSURANCE COMPANY DOES NOT ENDORSE OR CONDONE THE PURCHASE OR USE OF ANY INSURANCE PLANS BY ANY INDIVIDUAL. INSURANCE COMPANY ENDORSES THE PURCHASE OR USE OF INSURANCE PLANS ONLY UPON REQUESTED FROM THE INSURANCE COMPANY OR SUBSIDIARIES. You may not choose to purchase any supplemental insurance coverage without submitting a claim to the Insurance Company or SUBSIDIARY. Insurance Company cannot guarantee any specific rate or rate increase that may occur for any specific applicant on account of such supplemental insurance plan, particularly when insurance claims are involved. The premiums to the Supplemental Insurance Company may increase for several reasons, including, without limitation, actual or anticipated claims, premium increases caused by changes in the state of New York State insurance law or, under some circumstances, premium increases caused by changes in industry or general economic conditions. In no event will any premium in excess of the amounts specified in your supplemental policy be awarded to you in connection with claims under the supplemental policy unless you have fully complied with this information. INSURANCE COMPANY'S CERTIFICATE OF REPRESENTATION: Insurance Company's certificate of representation is required to be provided to any customer to assist in the determination of an applicant's eligibility to purchase a supplemental policy with the Insurance Company. The certificate of representation is a legal document. Except as otherwise provided in the certificate of representation, the Insurance Company or its affiliates makes no representation or warranty of any kind, express or implied, with respect to the information submitted. YOU ARE RESPONSIBLE FOR ASSUMING COMPLETE ACCURACY OF INFORMATION SUBMITTED BY YOU. If your application is incomplete, the Insurance Company could not issue you a supplemental policy.
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