Form Pcd 4016/nj - Application For Benefits Personal Injury Protection Page 2
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2Treating Doctor:
Family Doctor:
Street Address:
Street Address:
City, State, Zip:
City, State, Zip:
Phone:
Phone:
Were you were treated in a hospital? Yes o No o
If Yes, were you an in-patient? o Or out-patient? o
Hospital Name:
Phone Number:
Street Address:
Date of Hospital Treatment:
City, State, Zip:
Yes o No o
Have you ever had a similar injury?
(If Yes, please attach a further explanation - Type of accident, injury, approximate date of loss and all medical providers).
EMPLOYMENT INFORMATION
Do you have Health Coverage? Yes o No o
At the time of the accident, were you in the course of
Yes o No o
your employment?
If Yes, Name of Company:
Yes o No o
Health Insurance Primary?
Policy No. & Group No.:
Did you lose wages or salary as a result of your injury? Yes o No o If yes, amount lost to date: $
What is your average weekly wage or salary? $
If you lost wages, date disability from work began:
Date you returned to work:
Have you received, or are you eligible for, payments under:
Yes o
No o
(1) Any Worker’s Compensation Law?
Yes o
No o
(2) Employees Temporary Disability Benefit Statute?
Yes o
No o
(3) Medicare?
(4) Federal Law for Active and Retired Military Personnel? Yes o
No o
List Names and Address of your Employers for one year prior to the accident.
Employer & Address
Occupation
From:
To:
Employer & Address
Occupation
From:
To:
As a result of your injury, have you had any other expenses? Yes o No o If Yes, please attach a further explanation.
Have you been contacted by anyone other than your Insurance Company about this accident? Yes o No o
If Yes, please attach a further explanation.
I HAVE PERSONALLY COMPLETED AND REVIEWED THIS FORM. THE INFORMATION IS TRUE AND CORRECT
TO THE BEST OF MY KNOWLEDGE AND BELIEF.
Signature of Injured Person:
Date:
AUTHORIZATION FOR MEDICAL INFORMATION
This authorization or photocopy hereof 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 and physical findings, diagnosis and
prognosis. You are authorized to provide this information in accordance with the PERSONAL INJURY PROTECTION
BENEFITS LAW. This authorization shall remain valid for the duration of the claim.
SIGNATURE
DATE
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 authorized to provide this information in accordance with the PERSONAL INJURY
PROTECTION BENEFITS LAW. This authorization shall remain valid for the duration of the claim.
SIGNATURE
DATE
SOCIAL SECURITY NUMBER
FRAUD PREVENTION NEW JERSEY WARNING
ANY PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING
INFORMATION IS SUBJECT TO CRIMINAL AND CIVIL PENALTIES.
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