How to Fill Out a Michigan No-Fault Application for Benefits

If you’ve been injured in an accident, understanding how the Application for No-Fault Benefits works is essential. This form notifies the insurance company of your claim and is the first step in securing benefits under Michigan’s no-fault system.

Completing and submitting the application can be complicated, especially when you’re dealing with injuries. An experienced car accident attorney can help ensure the form is filled out correctly and submitted on time.

Filling out an Application for No-Fault Benefits involves several important steps, including:

• Identifying the insurance company responsible for your claim
• Providing basic information about the accident and your injuries
• Listing all known medical providers and treatment received
• Including employment information if you are claiming wage loss
• Reviewing the form carefully for accuracy before submitting

This video will teach you how to fill out a Michigan No-Fault Application for Benefits

Click here for a Printable Michigan No-Fault Application for Benefits Form. 

If you are injured in a car accident in Michigan, one of the most important steps you must take is filing out your application for no-fault benefits. This form must be completed and submitted to the proper insurance company within 1 year of the date of the accident.

Step one: general information.

First, at the top of the form, you’ll need to fill out today’s date, your name, and the date of the accident. Then, fill out the section with your legal name, address, date of birth, social security number, and contact information. Fill this out completely and accurately. Next, the form asks about the accident itself: the date, time, location, and what happened. Fill out the date and time of the crash, and circle A.M. or P.M. Fill in the location of the crash.

Provide a short explanation without too many details for the brief description of the accident section. A description might be, I was rear-ended while stopped at a red light. Do not guess about speed, make excuses, or speculate about what the other driver was doing. Next, you list the vehicles involved and any insurance policies that might apply. Include the vehicle owner’s name if you were not the owner, the insurance company name, auto insurance policy number if you have it. If you did not own a vehicle and did not have a family member living in the same house with you at the time of the accident who owned a vehicle, you should write none in that section.

Step two: medical.

Now we will update the medical section. This section is critical. List all injuries, even ones that seem minor right now. Examples of injuries to include are headaches, neck or back pain, dizziness, memory problems, shoulder, knee, or hip pain, anxiety, or sleep problems. If you do not include any injury or symptom in this section, the insurance company may deny your claim later. So, list every complaint, even if it seems minor at the time. Check the box under where you were treated by a doctor. If yes, list the names of the hospitals, clinics, and doctors who provided treatment to you. If you expect to have more treatment, check the yes box. If not, check no. And if unsure, check undetermined.

You also must fill out the section asking for your health insurance information. This includes private insurance, group insurance, HMOs, and government insurance, like Medicare and Medicaid. If you do not have health insurance of any type, write none above your name.

The next question is very important. It asks if you received medical treatment for the same or similar symptoms prior to this accident. For example, if you have ever, and I mean ever, even 15 years ago, had treatment for a low back strain and you suffered a back injury in this accident, you must disclose it on this form. You must do this for all injuries, aches, and pains caused in this crash. If you fail to put this information on the form, the insurance company will try to deny your claims later by contending you committed fraud by not disclosing previous conditions.

Step three: wage loss.

If you missed work because of the accident, this section matters. First, check yes or no to indicate if you received any workers’ compensation, social security benefits, or money under a wage or salary continuation plan. If you have received benefits, fill in the requested information. Next, check yes or no if you’re currently receiving unemployment benefits. For the next section, list the name and address of your employer, job title, and date of hire. If you have more than one employer, list all employers.

Step four: replacement services.

The last section is for replacement services, also called household services, and medical transportation. If you were provided with household help and had to drive or get transportation to medical appointments because of the crash, check the yes box. There are separate forms for those expenses, and you can watch our videos on how to fill those out.

Step five: sign and date.

Finally, sign and date the form on the second page. You also must sign and date the third page for authorization of medical information and authorization of wage and salary information, if you’re claiming wage loss benefits.

Step six: make copies.

Before you send it in, make a copy of everything and save it to your records. Send it by certified mail or email with delivery confirmation, or upload through the insurer’s portal and save screenshots.

Contact Buckfire Law For Help Filling Out Your No-Fault Application for Benefits Form

This video should help you with filling out this form, but feel free to call your lawyer or case manager at the Buckfire Law Firm if you have any questions.  If you do not have a lawyer and need assistance filing your insurance claims, call us now so we can help you every step of the way.