Njm Application For Benefits - Personal Injury Protection

CLAIM NO.

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 YOU MUST COMPLETE AND SIGN THIS FORM.

2. YOU MUST ALSO SIGN THE ATTACHED AUTHORIZATION (S).

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

DATE

OUR POLICYHOLDER

DATE OF ACCIDENT

TO:

CLAIMS DEPARTMENT

YOUR NAME

PHONE

HOME

BUSINESS

NO.

YOUR ADDRESS (NO., STREET, CITY OR TOWN, STATE AND ZIP CODE)

DATE OF BIRTH

SOCIAL SECURITY NO.

/

/

DATE AND TIME OF ACCIDENT

PLACE OF ACCIDENT (STREET, CITY OR TOWN AND STATE)

/

/

AM

PM

BRIEF DESCRIPTION OF ACCIDENT

............................................................................................................................................................................................................................................................................................................................

ARE THERE OTHER AUTOS IN YOUR HOUSEHOLD?

YES

NO

WERE YOU THE DRIVER OF THE AUTOMOBILE?

YES

NO

IF YES, LIST:

WERE YOU A PASSENGER IN THE AUTOMOBILE?

YES

NO

OWNERS

INSURERS

POLICY #

_____________________

____________________

______________

WERE YOU A PEDESTRIAN?

YES

NO

_____________________

____________________

______________

WERE YOU A MEMBER OF AUTOMOBILE OWNER’S HOUSEHOLD?

YES

NO

_____________________

____________________

______________

AS A RESULT OF THIS ACCIDENT WERE YOU INJURED?

YES

NO

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

........................................................................................................................................................................................................................................................................................................

WERE YOU TREATED BY A DOCTOR?

DOCTOR’S NAME AND ADDRESS

YES

NO

IF YOU WERE TREATED IN A HOSPITAL, WERE YOU

HOSPITAL’S NAME AND ADDRESS

AN IN-PATIENT?

AN OUT-PATIENT?

AMOUNT OF MEDICAL

WILL YOU HAVE MORE MEDICAL

AT THE TIME OF YOUR ACCIDENT WERE YOU IN THE

BILLS TO DATE: $

EXPENSES? YES

NO

COURSE OF YOUR EMPLOYMENT?

YES

NO

DID YOU LOSE WAGES OR SALARY AS A RESULT OF

IF YES, AMOUNT

WHAT IS YOUR AVERAGE

YOUR INJURY? YES

NO

LOST TO DATE $

WEEKLY WAGE OR SALARY? $

IF YOU LOST WAGES:

DATE DISABILITY

DATE YOU RETURNED

FROM WORK BEGAN

/

/

TO WORK

/

/

HAVE YOU RECEIVED OR ARE YOU ELIGIBLE FOR ANY

YES

NO

BENEFITS UNDER:

(1) ANY WORKERS’ COMPENSATION LAW?

IF YES, AMOUNT

(2) EMPLOYEES TEMPORARY DISABILITY BENEFIT STATUTE?

$

(3) MEDICARE?

PER WEEK

PER MONTH

LIST THE NAMES AND ADDRESSES OF YOUR EMPLOYER AND OTHER EMPLOYERS FOR ONE YEAR PRIOR TO ACCIDENT DATE AND GIVE OCCUPATION AND DATES OF EMPLOYMENT:

...........................................................................................................................................................................................................................................................................................

EMPLOYER AND ADDRESS

OCCUPATION

FROM

TO

...........................................................................................................................................................................................................................................................................................

EMPLOYER AND ADDRESS

OCCUPATION

FROM

TO

...........................................................................................................................................................................................................................................................................................

EMPLOYER AND ADDRESS

OCCUPATION

FROM

TO

AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES?

YES

NO.

IF YES, ATTACH EXPLANATION AND AMOUNTS OF SUCH EXPENSES.

“Any person who knowingly and with intent to defraud any insurance company or other person fi les a statement of claim containing any materially false

information or conceals for the purpose of misleading, information concerning any fact material thereto commits a fraudulent insurance act, which is

a crime and subjects such person to criminal prosecution and civil penalties.”

SIGNATURE:

DATE:

DO NOT DETACH

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.

DATE

SIGNATURE

DO NOT DETACH

AUTHORIZATION FOR WAGE & 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.

DATE

SIGNATURE

SOCIAL SECURITY NO.

New Jersey Manufacturers Insurance Company

New Jersey Re-Insurance Company

New Jersey Casualty Insurance Company

■

■

New Jersey Indemnity Insurance Company

AC-PIP-1J (6/07)