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Personal Injury and Medical Payments Forms

State Farm® provides Personal Injury Protection (PIP) and/or Medical Payments Coverage (MPC) forms for your information. Talk to your claim associate about forms that may be needed for your claim.

Connecticut, Maine, New Hampshire, Rhode Island, and Vermont Medical Payments Coverage (MPC) Policyholders and Injured Parties

Medical Authorization

New Jersey Personal Injury Protection (PIP)

Forms to be Completed, Printed, Signed and Returned by the Injured Party

Application for PIP Benefits

Affidavit of No Insurance

Essential Services Form

Medical Authorization

Wage and Salary Verification

Policyholders, Injured Parties and Medical Providers

Claim Information Sheet — Basic Policy

Claim Information Sheet — Standard Policy

Attending Provider Treatment Plan

New Jersey PIP Pre-Service Approval Form

New Jersey PIP Post-Service Appeal Form

Claims with Date of Loss Prior to 11/1/2011

Decision Point Review Plan

Medical Provider Package/Conditional Assignment of Benefits

Claims with Date of Loss On and After 11/1/2011

Decision Point Review Plan

Medical Provider Package/Conditional Assignment of Benefits

Claims with Date of Loss On and After 12/15/2013

Decision Point Review Plan

Medical Provider Package/Conditional Assignment of Benefits

Dates of Service On or After 12/1/2017

Decision Point Review Plan

Medical Provider Package/Conditional Assignment of Benefits

PIP Vendor

PIP Vendor Consolidated Services Group (CSG)

New York Personal Injury Protection (PIP)

Policyholders and Injured Parties

NF-AOB Assignment of Benefits Form

NF-1A Cover Letter

NF-2 Application for Motor Vehicle No-Fault Benefits

NF-3 Verification of Treatment by Attending Physician or Other Provider of Health Service

NF-4 Verification of Hospital Treatment

NF-5 Hospital Facility Form

NF-7 Verification of Self-Employment Income

NF-8 Agreement to Pursue Social Security Disability Benefits

NF-9 Agreement to Pursue Workers Compensation or N.Y.S. Disability Benefits

NF-11 Additional PIP Subrogation Agreement

NF-12 Lump-Sum Settlement Agreement

NF-13 Election of Option – Optional Basic Economic Loss Coverage

Pennsylvania Medical Payments Coverage (MPC)

Policyholders and Injured Parties

Application for Benefits

Medical Authorization