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If You're Hurt in a Car Accident

Personal Auto Claims Forms

We've gathered all the forms and information you need if your vehicle is damaged or you're injured in an auto accident.

Connecticut

Physical Damage Forms

Connecticut Driver's Statement
Connecticut Claimant's Report

Medical Services Forms

Application for Benefits must be completed by the injured party.

Employers must fill out a Wage and Salary Verification Form for an injured party to be reimbursed for lost wages.

Maryland

Physical Damage Forms

Maryland Driver's Statement
Maryland Claimant's Report

Medical Services Forms

Application for Benefits must be completed by the injured party and returned to NJM no later than one year from the date of the accident.

Employers must fill out a Wage and Salary Verification Form for an injured party to be reimbursed for lost wages.

New Jersey

Physical Damage Forms

New Jersey Driver's Statement
New Jersey Claimant's Report

PIP: It's the Law

New Jersey law includes Decision Point Review, Precertification, and Notification Requirements for patients who are injured in auto accidents and their medical providers.

Voluntary Medical Network

Preferred Medical Providers

Learn about the Use of Telemedicine and Telehealth During the Coronavirus Pandemic.

Medical Services Forms

Application for Benefits must be completed by the injured party.

Employers must fill out a Wage and Salary Verification Form for an injured party to be reimbursed for lost wages.

Important No-Fault medical information for the insured.

Important requirements for the health care provider.

Health care providers must send their treatment plans to NJM in writing using the Attending Provider Treatment Plan (APTP) Form.

All requests for surgical procedures (CPTs 10000–69999) have to be submitted with the Surgery Precertification Request NJ No-Fault Claims Form.

All requests for pre-service appeal must include a fully completed New Jersey Pre-Service Appeal Form faxed to the appropriate NJM office below.

All requests for post-service appeal must include a fully completed New Jersey Post-Service Appeal Form faxed to NJM at 1-609-963-6075.

Precertification Mail

NJM Insurance Group
Attn: PIP Department
301 Sullivan Way
PO Box 928
West Trenton, NJ 08628-0278

Precertification Fax

1-609-493-1277 West Trenton
1-609-493-1565 Parsippany
1-609-493-1474 Hammonton

Ohio

Physical Damage Forms

Ohio Driver's Statement
Ohio Claimant's Report

Medical Services Forms

Application for Benefits must be completed by the injured party.

Pennsylvania

Physical Damage Forms

Pennsylvania Driver's Statement
Pennsylvania Claimant's Report

Medical Services Forms

Application for Benefits must be completed by the injured party.

Employers must fill out a Wage and Salary Verification Form for an injured party to be reimbursed for lost wages.

The information contained on this page should not be construed as legal, financial or insurance advice. The coverage afforded for a particular loss depends on the specific facts and the terms, exclusions, and limits of the actual policy. Nothing on this site alters the terms or conditions of any policy; the policy controls coverage. Coverage options, limits, discounts, deductibles, and other features are subject to underwriting criteria, state availability, and effective dates. Coverage provided and underwritten by NJM Insurance Company and its subsidiaries, 301 Sullivan Way, W. Trenton, NJ 08628.