Application For Benefits - Personal Injury Protection
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1
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3APPLICATION FOR BENEFITS – PERSONAL INJURY PROTECTION
Date:
Our Policyholder:
Date of Accident:
Claim Number:
New Jersey Skylands Insurance
Return To:
P.O. Box 5155
Buffalo, NY 14240-5155
1. To enable us to determine if you are entitled to benefits under the personal injury protection law, you must COMPLETE and SIGN this form.
Important:
2. You must also SIGN the attached authorizations.
3. Please return all the completed forms to us promptly.
Home:
Your Name:
Telephone Numbers:
Office:
Date of Birth:
Street Address:
Apartment#:
Your
Social Security
Address:
City, State, Zip Code:
Number:
Accident Location
Date & Time
(Street, City or Town, and
of Accident:
State):
Description
of Accident:
Yes
No
Were you the driver of the automobile?
Yes
Yes
No
Do you or any member of
Were you a passenger in the automobile?
Yes
No
your household own an
Were you a pedestrian?
automobile?
No
Were you a member of the automobile owner’s household?
Yes
No
Owner’s
Insurance
If yes, Name of Owner:
Company:
Yes
Were you injured as a
If your answer is YES, complete the
Signature:
Date:
rest of this form. If NO, sign here and
result of this accident?
No
return this form to us.
Describe your injury: (list
all injured body parts and
describe nature of
symptoms)
Were you treated by a doctor?
Doctor’s name and address:
Yes
No
Hospital
Hospital Name:
Acct#:
If you were treated in a
Hospital
Hospital Street
hospital were you an:
Information:
Address:
Hospital City,
Inpatient
Outpatient
State, Zip:
Will you have more medical
Amount of Medical
At the time of your accident were you acting in the course of your employment?
expense?
$
Bills incurred to date:
Yes
No
Yes
No
Did you lose wages or salary as a result of your
If yes,
injury?
amount
What is your average weekly
$
$
lost to
wage or salary?
Yes
No
date:
Date Disability from
If you lost wages:
Date you returned to work:
work began:
Yes
No
Have you received or
1. Any Worker’s Compensation Law?
If yes, provide amount
are you eligible for
2. Employees Temporary Disability Benefit Statute
Per Week
$
Yes
No
benefits under:
3. Medicare?
Per Month
Yes
No
List names and addresses of your employer and other employers for one year prior to accident date and give occupation and dates of employment for each:
Employer Name and Address
Occupation
From
To
Employer Name and Address
Occupation
From
To
Employer Name and Address
Occupation
From
To
As a result of your injury, have you had any other
expenses?
Yes
No
If yes, explain on reverse side
Signature:
Date:
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