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Application For Benefits

Michigan Motor Vehicle No-Fault Insurance Law

The no-fault law provides benefits for medical expenses, wage loss and replacement services, as well as survivors' loss. To enable us to determine if you are entitled to any of these benefits, please complete the application form below.

IMPORTANT – TO BE ELIGIBLE FOR BENEFITS, YOU MUST: 

(1) Complete, sign & return this application no later than one (1) year from the date of the accident.
(2) Submit bills for expenses promptly, but no later than one (1) year from the date the expense was incurred.
(3) Sign the attached authorization(s).

Need help completing this form?
Call us at (248) 945-0100

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AUTHORIZATION FOR MEDICAL INFORMATION

This authorization or photocopy hereof, will authorize a physician, hospital, clinic, or other medical institution to furnish all information you may have regarding my condition while under your observation or treatment; including the history obtained, x-ray and physical findings diagnosis and prognosis. You are required to provide this information in accordance with the Michigan motor vehicle no-fault insurance law, P.A. 294 of the Public Acts of 1972.

AUTHORIZATION FOR WAGE AND SALARY INFORMATION

This authorization or photocopy hereof, will authorize you to furnish all information you may have regarding my wages or salary while employed by you. You are required to provide this information in accordance with the Michigan motor vehicle no-fault insurance law. P.A. 294 of the Public Acts of 1972.

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When a catastrophic life event occurs, you need personal attention from experienced litigators that will help you understand every facet of your case. Talk to one of our compassionate attorneys today, completely free of obligation.

"David and Ryan made sure that I always had any questions or concerns addressed in a timely manner. I appreciated their compassion, and understanding as I got emotional. The reassurance they provided made me feel important and valued as a client."

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Client Testimonials

I HIGHLY recommend David Moss; he exceeded my expectations numerous times, and I feel fortunate and blessed to have worked with him and his team. Moss & Colella attorneys have relentless perseverance and dedication for everyone they represent.
If this firm takes your case, it's in exceptionally experienced hands. The hands of attorneys who care about your well-being and the outcome of your litigation!
When I got into a car accident, my life changed. David and Ryan understood how this change affected my livelihood and mobility. They handled my case professionally, and I couldn't be more thankful for all of the sincere guidance and help provided throughout this process.
Thanks so much for everything!!!

The Burls

Client

 I was referred to Moss & Colella in 2018 following a car accident. I cannot tell you how confident and safe I felt knowing that I was in good hands. David, and Ryan made sure that I always had any questions or concerns addressed in a timely manner. I appreciated their compassion, and understanding as I got emotional, and the reassurance they provided, made me feel important and valued as a client. If you need a great lawyer for an injury, this is your firm! I hope I never need to be in a position where I’d need their help again, but if I did, I’d gladly seek their services!

T. Ray

Client

My son sadly passed after a vehicle accident, it was a hard case. Mr. Moss was our lawyer, he was very helpful, very informative, very up front and put alot of effort into this case. He’s a great man, a honest man and his law firm will do the best with any case brought to them. Everyone at his office was very kind and very helpful. I absolutely recommend them for any of your lawsuit needs.
Very grateful for this firm!

S. Collins

Client

Words can not express how grateful I am for the outcome of this case. It was truly a blessing to have this resolved sooner than expected. But without your help and my faith in your firm along with my faith on God, this may not have been possible. I appreciate everything you have done in orchestrating everything to this resolve, for your time and effort meant the world to me. I thank my friend for putting me in touch with such a talented group of people. You will always be considered my attorneys of choice for anything that comes up in the future that would render your services. This year has definitely been many blessings so far and I welcome many more to come. Thank you again for everything and may you continue to be blessed.

Janene

Mother of Client

Very few people on this earth impress me. You are one of the very few. My family and I thank you for all you did. You are a good man!

Jason

Client

Other law firms would not take my case, they said it was too complicated. But David Moss took my case and got the result I was looking for in almost no time at all. I’m glad I didn’t listen to those other lawyers.

Anonymous

Client

I just wanted to thank you for putting your time and effort into my case. You did a wonderful job last Thursday. You are what people say you are, a wonderful lawyer.

Adam

Client

I do not only count on you as one bad ass lawyer, but also a friend. None of this would be possible without you. My deepest gratitude to you, Vic and all of the Moss & Colella team.

Anonymous

Client

I am very relieved and very happy with the outcome. I appreciate everything you and your firm did to see this through and I will be grateful for that always. You all came highly recommended and now I see why based on what you did in helping my son through a very challenging moment in his life. We will always be your fans:) Thank you again and may you always be Blessed…

Anonymous

Mother of Client

About the Firm

The attorneys of Moss & Colella have carefully chosen their career paths to fight for those that have suffered from injury and wrongful death. We believe every citizen should have the right to hire the best lawyer who will actively advocate for their case.
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David Moss and Vince Colella have over 60 collective years of personal injury trial experience that provides you a level of legal services and success unmatched by other firms. By working together, we have the ability to find creative, effective, and efficient solutions to even the most complex cases. No matter what situation you face, we will help you get through it.

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