Form Pcd 4016/nj - Application For Benefits Personal Injury Protection printable pdf download

Form Pcd 4016/nj - Application For Benefits Personal Injury Protection

APPLICATION FOR BENEFITS

PERSONAL INJURY PROTECTION

APPLICATION FOR BENEFITS – PERSONAL INJURY PROTECTION

IMPORTANT:

1. TO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE PERSONAL

INJURY PROTECTION LAW, PLEASE COMPLETE AND SIGN THIS FORM.

2. YOU MUST ALSO SIGN THE AUTHORIZATION (S) ON REVERSE SIDE.

3. RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE RECEIVED TO DATE.

4. UNDER PENALTY OF LAW, THE INJURED PERSON MUST COMPLETE AND SIGN THIS FORM.

INSURANCE COMPANY INFORMATION

(From Insurance ID Card)

Company Name:

Claim Number: *

(*If, available)

Street Address:

Claim Representative:*

City, State, Zip:

Phone No:*

Fax No:

Policyholder:

Policy No:

INJURED PERSON’S INFORMATION

Name:

Date of Birth:

Street Address:

Social Security No.:

City, State, Zip:

Home Phone:

Address on Date of Accident

Business Phone:

(if different from current address)

Street Address:

Driver’s License No:

City, State, Zip:

Do you or any member of your household

Were you the Driver of the Vehicle?

Yes o No o

own or lease an automobile?

Yes o No o

Were you a Passenger in the Vehicle?

(If YES, list name, address and phone number).

Were you a Pedestrian?

Yes o No o

Were you a Resident Relative of the

Automobile Owner’s Household?

Yes o No o

Are you Married?

If Yes:

(If, YES – Identify that Familial Relationship)

Spouse’s Name:

Street Address:

City, State, Zip:

ACCIDENT INFORMATION

Accident Date:

Street Address:

AM o PM o

Accident Time:

City or Town, State:

Brief Description of Accident (To be completed by the individual signing this Form).

INJURY INFORMATION

Yes o No o

As a result of this accident, were you injured:

If your answer is YES, complete the rest of this Form – if NO, sign here and return this Form to us.

SIGNATURE________________________________________________________ DATE_______________________

Describe your Injury SPECIFICALLY: (To be completed by the individual signing this Form).

Yes o No o

Yes o

No o

Were you treated by a Doctor?

Do you have a family Doctor?

See Reverse Side

PCD 4016/NJ Ed. 12/02

Form Pcd 4016/nj - Application For Benefits Personal Injury Protection

Related Articles

Related forms

Related Categories