ALOG In THAI CI TURKISH CI URDU O VIETNAMESE Visit Date: AR;2 IL- IS, 0 YIDDISH DO NOT SCAN THIS DOCUMENT EFTA00311069 MOTOR VEHICLE NO-FAULT INSURANCE LAW ASSIGNMENT OF BENEFITS FORM (FOR ACCIDENTS OCCURRING ON AND AFTER 3/1/02) , ("Assignor") hereby assign to (Print patient's name) , ("Ass