Application For No-fault Benefits

KACP Application Process

Application

  • Complete the online KY No-fault Benefits Application, print, sign and mail the original to our office along with a copy of the Police Report, if available.
  • When mailed application is received by KACP, we will review for assignment to an insurance carrier.
  • If the application is accepted, you will be sent a letter informing you of the insurance carrier contact information. The carrier is responsible for assigning you a claim number and investigating eligibility.
  • If the application is rejected by KACP, you will be sent a letter explaining why it was not accepted.
  • If further information is needed to review your application, KACP will send you a letter explaining what information is needed. Once that information is returned, your application will be reconsidered for assignment.
Download Application (PDF)

Warning

Any person who knowingly and with intent to defraud any insurance company or other person files a statement of claim containing any materially false information or conceals, for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is a crime. You are required to provide this information in accordance with KRS 304.39-160.

Authorization for Medical Information

This authorization or photocopy thereof will authorize you to furnish all information you may have regarding my condition while under your observation or treatment including the history obtained, X-Ray physical findings, diagnosis and prognosis. You are authorized to provide this information in accordance with the Personal Injury Protection Benefits (Kentucky No-Fault Law)

Authorization for Wage and Salary Information

This authorization or photocopy thereof will authorize you to furnish all information you may have regarding my wages or salary while employed by you. You are authorized to provide this information in accordance with the Personal Injury Protection Benefits (Kentucky No-Fault Law)