Form I-80 "Health Insurance Update Form" - New York

What Is Form I-80?

This is a legal form that was released by the New York State Office of Victim Services - a government authority operating within New York. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • The latest edition provided by the New York State Office of Victim Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form I-80 by clicking the link below or browse more documents and templates provided by the New York State Office of Victim Services.

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Download Form I-80 "Health Insurance Update Form" - New York

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ANDREW M. CUOMO
ELIZABETH CRONIN ESQ.
Governor
Director
HEALTH INSURANCE UPDATE FORM
(TO BE COMPLETED BY CLAIMANT)
CLAIMANT NAME:
CLAIM NUMBER:
Are you now receiving or currently applying for any medical insurance coverage? Yes____ No____
Complete the following table for each person receiving benefits under this claim. Please include current and
pending insurances.
Company Name
Effective
Insurance
Policy No.
Persons Covered
Date
Blue Cross
Blue Shield
Medicare
Medicaid
Major Medical
Union
HMO
Veteran’s Admin.
Workers Comp.
Dental Insurance
Vision Benefits
Prescription Drug
Program
No Fault/MVAIC
Other Insurance
If your insurance coverage has terminated or changed since you were awarded benefits, you must submit a
termination of benefit statement from your former insurance carrier, and if applicable, a statement, or copy
of your benefit card from your new insurance carrier listing the effective date of coverage.
I hereby certify that the above information is true and correct to the best of my knowledge. I also understand that
knowingly submitting falsified information to the Office of Victim Services is a crime.
Payments may be delayed if this form is not received within thirty (30) days.
d
Claimant’s Signature
Date
*I-80*
Alfred E. Smith State Office Building, 80 South Swan Street, Albany, NY 12210 │ 800-247-8035 │ovs.ny.gov
ANDREW M. CUOMO
ELIZABETH CRONIN ESQ.
Governor
Director
HEALTH INSURANCE UPDATE FORM
(TO BE COMPLETED BY CLAIMANT)
CLAIMANT NAME:
CLAIM NUMBER:
Are you now receiving or currently applying for any medical insurance coverage? Yes____ No____
Complete the following table for each person receiving benefits under this claim. Please include current and
pending insurances.
Company Name
Effective
Insurance
Policy No.
Persons Covered
Date
Blue Cross
Blue Shield
Medicare
Medicaid
Major Medical
Union
HMO
Veteran’s Admin.
Workers Comp.
Dental Insurance
Vision Benefits
Prescription Drug
Program
No Fault/MVAIC
Other Insurance
If your insurance coverage has terminated or changed since you were awarded benefits, you must submit a
termination of benefit statement from your former insurance carrier, and if applicable, a statement, or copy
of your benefit card from your new insurance carrier listing the effective date of coverage.
I hereby certify that the above information is true and correct to the best of my knowledge. I also understand that
knowingly submitting falsified information to the Office of Victim Services is a crime.
Payments may be delayed if this form is not received within thirty (30) days.
d
Claimant’s Signature
Date
*I-80*
Alfred E. Smith State Office Building, 80 South Swan Street, Albany, NY 12210 │ 800-247-8035 │ovs.ny.gov