Personal Injury Protection (PIP) and Medical Payments Coverage (MPC) Forms and Information

These forms are not eligible to be used by residents of the province of New Brunswick, Canada

New Jersey Personal Injury Protection (PIP)

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

Forms to be completed, printed, signed and returned by the Injured Party.

Affidavit of No Insurance (PDF 47 KB)
Application for PIP Benefits (PDF 1003 KB)
Essential Services Form (PDF 26 KB)
Medical Authorization (PDF 1336 KB)
Wage and Salary Verification (PDF 1012 KB)

Policyholders, Injured Parties and Medical Providers

Claim Information Sheet - Basic Policy (PDF 129 KB)
Claim Information Sheet - Standard Policy (PDF 137 KB)
Decision Point Review Plan (PDF 176 KB) - for claims with Date of Loss prior to 11/1/2011.
Medical Provider Package/Conditional Assignment of Benefits (PDF 259 KB) – for claims with Date of Loss prior to 11/1/2011
Decision Point Review Plan (PDF 132 KB) - for claims with Date of Loss on and after 11/1/2011
Medical Provider Package/Conditional Assignment of Benefits (PDF 224 KB) – for claims with Date of Loss on and after 11/1/2011
Consolidated Services Group (CSG) – PIP Vendor
Attending Provider Treatment Plan (PDF 67 KB)
Internal Dispute Resolution Request Form (PDF 93 KB)

Connecticut/Maine/New Hampshire/Rhode Island/Vermont Medical Payments Coverage (MPC)

Policyholders and Injured Parties

Medical Authorization (PDF 73 KB)

Pennsylvania Medical Payments Coverage (MPC)

Policyholders and Injured Parties

Application for Benefits (PDF 84 KB)
Medical Authorization (PDF 73 KB)

New York Personal Injury Protection (PIP)

Policyholders and Injured Parties

NF-AOB Assignment of Benefits Form (PDF 71 KB)
NF-1A Cover Letter (PDF 87 KB)
NF-2 Application for Motor Vehicle No-Fault Benefits (PDF 115 KB)
NF-3 Verification of Treatment by Attending Physician or Other Provider of Health Service (PDF 105 KB)
NF-4 Verification of Hospital Treatment (PDF 87 KB)
NF-5 Hospital Facility Form (PDF 101 KB)
NF-7 Verification of Self-Employment Income (PDF 77 KB)
NF-8 Agreement to Pursue Social Security Disability Benefits (PDF 65 KB)
NF-9 Agreement to Pursue Workers’ Compensation or N.Y.S. Disability Benefits (PDF 57 KB)
NF-11 Additional PIP Subrogation Agreement (PDF 59 KB)
NF-12 Lump-Sum Settlement Agreement (PDF 56 KB)
NF-13 Election of Option – Optional Basic Economic Loss Coverage (PDF 58 KB)

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