New Jersey Personal Injury Protection (PIP) Forms and Information

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This contains explanations, forms and links that will help you better understand the process of your New Jersey Personal Injury Protection (PIP) claim.

Policyholders and Injured Parties

Affidavit of No Insurance (PDF 109 KB)
Application for PIP Benefits (PDF 31 KB)
Claim Information Sheet - Basic Policy (PDF 125 KB) - With endorsement 6126HS. All others should contact their assigned claim handler.
Claim Information Sheet - Standard Policy (PDF 133 KB) - With endorsement 6126HS. All others should contact their assigned claim handler.
Decision Point Review Plan (PDF 55 KB)
Essential Services Form (PDF 72 KB)
Medical Authorization (PDF 127 KB)
New Jersey Department of Banking and Insurance Approval Letter (PDF 88 KB) - For State Farm Decision Point Review Plan
Wage and Salary Verification (PDF 335 KB)
Consolidated Services Group (CSG) - Medical Services Vendor

Providers

Affidavit of No Insurance (PDF 109 KB)
Application for PIP Benefits (PDF 31 KB)
Attending Provider Treatment Plan (PDF 16 KB)
Conditional Assignment of Benefits (PDF 70 KB) - With endorsement 6126HS. All others should contact the assigned claim handler.
Decision Point Review Plan (PDF 55 KB)
Department of Banking and Insurance-Order 1-104-143 (PDF 26 KB)
Internal Dispute Resolution Request Form (PDF 24 KB)
Medical Provider Package/Decision Point Review Plan Summary (PDF 86 KB)
New Jersey Department of Banking and Insurance Approval Letter (PDF 88 KB) - For State Farm Decision Point Review Plan
Consolidated Services Group (CSG) - Medical Services Vendor