** REMINDER: THIS FORM DOES NOT REPLACE THE VF-2 **

• Fire Districts of NY Mutual Insurance Co., Inc.

• FDM Preferred Insurance Co., Inc.

• Fire Districts Insurance Co., Inc.

“PROTECTOR OF THE PROTECTORS”_

FDMfast fax “Notice of Injury”

Fire Districts/Political Subdivision:

Fire Company:

Injured Person:

Volunteer: - Commissioner: - Paid Employee:

Home Address:

Home Phone:   Date of Birth:  Social Security#

Date and Time of Injury:

Location of Accident:

Description of Accident:

Nature of Injury & Part(s) of Body Affected:

Name and Address of Medical Provider and/or Hospital:

Losing Time From Work:   Yes   No  - If Yes, Indicate First Day Out:

**PLEASE ADVISE THE MEDICAL PROVIDER/HOSPITAL TO FORWARD ALL BILLS AND REPORTS DIRECTLY TO US!

Fire Districts of New York Mutual Insurance Company, Inc.

777 Chestnut Ridge Road, Suite 302, Chestnut Ridge, NY 10977-5670

ATTENTION: Claim Department

845-352-8855 888-314-3004

845-352-2022 Fax