Michigan No-Fault forms

Application for No-Fault insurance benefits, and forms for attendant care, replacement services, wage and salary verification, and attending physician reports

Below is a list of forms and applications for No-Fault insurance benefits. These include forms for attendant care, replacement services, wage and salary verification, as well as attending physician reports (APRs).

Our attorneys have provided these forms to help you apply for your No-Fault benefits and to make sure your medical expenses, attendant care and replacement services are reimbursed after a serious auto accident.

Please do not submit these forms to your auto insurance company without first reviewing them with your lawyer.

Application for No-Fault benefits

You must complete this form to apply for Michigan No-Fault insurance benefits. This is a sample application. Your auto insurance company may require you to fill out its own form.

Attending physician’s report

Your doctor must complete this form, which relates your injuries to the auto accident to prove that you are eligible for No-Fault insurance benefits, including reimbursement of your medical expenses.

Work disability certificate

Your doctor must complete this form, which is a prescription for your time off of work due to your auto accident-related injuries.

Wage verification

Your employer must complete this form, which documents your salary and employee benefits, in order to calculate and receive your wage loss benefits.

Replacement services disability certificate

Your doctor must complete this form to show that you need help with household chores and caring for young children, due to your accident-related injuries.

Transportation expense log

You must complete this form, to record your mileage for medical appointments related to the accident, in order to be reimbursed for the mileage.

Household services statement

The person who helps you with your replacement services (chores around the house) must complete this form, which keeps track of what they’re doing around the house, in order to be reimbursed $20 a day.

Attendant care disability certificate

Your doctor must complete this form, which says that you require in-home nursing services (physical care) due to your accident-related injuries.

Affidavit of attendant care services performed

The person who provides your in-home nursing services must complete this form to keep track of the services and to be reimbursed.

Michigan Assigned Claims c/o Michigan Automobile Insurance Placement Facility

This form is used to make a claim for No-Fault insurance benefits to the Michigan Automobile Insurance Placement Facility (Michigan Assigned Claims Plan), as a last resort to receive benefits.

Help from our insurance attorneys

For help from one of our lawyers today, call Michigan Auto Law at (800) 968-1001.

We’re happy to help you fill out these forms, to make sure you receive all of the benefits and assistance you’re entitled to while you recover.