Application For Benefits - Personal Injury Protection (Page 3 of 3) in pdf

IM PO RTANT: CHO O SE O NE O F THE REIMBURSEMENT METHO DS LISTED BELO W .

___ PLEASE PAY ME DIRECTLY

_X___ PLEASE PAY MY MEDICAL PRO VIDER DIRECTLY

IF W E PAY YO U DIRECTLY, YO U W ILL BE RESPO NSIBLE FO R PAYING YO UR M EDICAL PRO VIDERS PRO M PTLY, IF YO U FAIL

TO PAY YOUR MEDICAL PROVIDERS PROM PTLY, COLLECTION PROCEEDINGS AND INTEREST CHARGES M AY BE BROUGHT

AGAINST YOU.

YO U MAY DIRECT THE PAYMENT O F PERSO NAL INJUR Y PRO TECTIO N CO VERAG E TO THE DIFFERENT CO VERED EXPENSES

(W AGE LO SS, REPLACEMENT SERVICES, AND/O R MEDICAL EXPENSES) UNDER PIP ON A PRO SPECTIVE BASIS. PLEASE

DESCRIBE, IN W RITING, HOW YOU W OULD LIKE YOU PERSONAL INJURY PROTECTION BENEFITS TO BE DISTRIBUTED AMONG

THE DIFFERENT CO VERED EXPENSES UNDER PIP.

____________________________________________________________________________________________________________

________________________________________________________________________________________________________________

IF YO U DO NO T DESCR IBE, IN W RITING , HO W YO U W O ULD LIKE YO UR PERSO NAL INJUR Y PRO TECTIO N BENEFITS TO BE

DISTRIBUTED, THEN BENEFITS W ILL BE PAID O N A MO NTHLY BASIS AS YO U INCUR MEDICAL EXPENSES, W AG E LO SS, AND/O R

REPLACEMENT SERVICES LOSS.

NO TE THAT THE MAXIMU M AMO UNT W E W ILL PAY FO R W AG E LOSS O R REPLAC EMENT SERVICES IN ANY O NE W EEK IS $200.

-DO NOT DETACH-

IF YO U ARE CLAIMING MEDICAL EXPENSES, PLEASE SIG N THE FO LLO W ING :

AUTHO RIZATIO N FO R M EDICAL INFO RM ATIO N

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 (Kentucky No-Fault) Law.

Signature

Date

IF YOU ARE CLAIMING LOST W AGES, PLEASE SIGN THE FOLLOW ING:

AUTHORIZATION FOR W AGE AND SALARY INFORM ATION

This authorization or photocopy hereof w ill authorize you to furnish all inform ation you may have regarding my

w ages or salary w hile em ployed by you. You are authorized to provide this inform ation in accordance w ith

Personal Injury Protection Benefits (Kentucky No-Fault) Law .

Signature

Date

Social Security No. ________________________________

Application For Benefits - Personal Injury Protection Page 3