Can this form be signed electronically?

Yes. Electronic signatures generally satisfy legal requirements under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention are demonstrable.

Does the form ever require notarization?

Most carriers do not require notarization for PIP elections, but state rules or insurer-specific requirements can differ. Confirm with the insurer or state regulator before notarizing.

What if the name or policy number is incorrect?

Errors can cause claim delays. Correct the form promptly and provide a signed amendment or an insurer-approved replacement to ensure the election is applied.

How do I revoke or change an election?

Changes require a clear written amendment or new election accepted by the insurer; follow carrier procedures and retain both records. Legal consequences may vary by state and carrier.

What supporting documents should accompany the form?

Provide policy declarations, proof of identity, and vehicle information; include medical releases only if required and ensure HIPAA protections for PHI.

How long before the insurer applies the election?

Processing times vary by carrier and intake channel; digital submissions with complete data and authentication typically process faster than mailed forms.

Electronic Signature
Templates
Insurance
Insurance PIP Choice Form

Insurance PIP Choice Form

This template is fully customizable. Edit the text, fill out the fields, and send it for signature. Give it a try!

INSURANCE PIP CHOICE FORM

Applicant / Insured Information

Insured Full Legal Name Date of Birth Residential Address

Primary Phone

Email Address

Driver's License or ID Number

Policy Details

Insurer Name:

Policy Number:

Policy Period: From through

Vehicle / Exposure Type

Private passenger automobile Commercial automobile Motorcycle Other (describe below)

PIP Coverage Selection

Select one of the following PIP benefit options. Only one selection may be elected. The selection made below governs medical expense, attendant care, replacement services and related PIP benefits under the policy during the policy period identified above.

Statutory minimum PIP benefits as required by applicable law Extended PIP — Medical Expense Limit $25,000 Extended PIP — Medical Expense Limit $50,000 Extended PIP — Medical Expense Limit $100,000 Other limit (specify amount)

Deductible and Premium

Select deductible applicable to PIP medical expense payments (if available under the policy):

No deductible $250 deductible $500 deductible Other deductible (specify)

Additional Premium for Selected Options

Covered Benefits (Check applicable)

Medical expenses (subject to selected limit and deductible) Lost wages reimbursement Replacement services / household assistance Death benefit (specify beneficiary below)

Exclusions and Limitations

The following are common exclusions to PIP benefits under this policy and are included here as binding limitations unless otherwise provided by statute or by specific written endorsement: care not related to the covered incident; injuries sustained in the commission of a felony; benefits for injuries covered by workers' compensation where recovery is available; services not prescribed by a licensed provider; costs for care received outside the policy period. This list is not exhaustive. Any additional exclusions or limitations specific to this policy are set forth in the policy contract.

Coordination of Benefits and Subrogation

By signing below, the insured acknowledges that the insurer may coordinate PIP benefits with other available benefits and may assert subrogation or reimbursement rights against any third party or other insurer to the extent PIP benefits are paid. The insured authorizes the insurer to obtain records and to pursue recovery on behalf of the insured when permitted by law.

I acknowledge coordination/subrogation terms I acknowledge and accept coordination of benefits and subrogation provisions

Beneficiary / Death Benefit Information (if applicable)

Complete the following only if Death Benefit is selected above. Beneficiary designation applies to PIP death benefits only and is subject to policy terms.

Beneficiary Full Name

Relationship to Insured

Share Percentage

Waiver / Declination of PIP (If selecting to decline)

If you elect to decline PIP medical benefits or limit PIP coverage permitted by law, check the applicable box and sign below. Declining or limiting PIP may affect your ability to recover medical expenses through this policy.

I decline PIP medical expense benefits I elect PIP for medical expenses only (no lost wages or replacement services)

Reason for Declination or Limitation (if applicable)

Certification and Authorization

By signing below, I certify under penalty of perjury that the information provided on this form is true and accurate to the best of my knowledge. I understand the selection I make on this form will apply for the policy period indicated and may be binding until the policy's next renewal unless changed by written endorsement. I authorize the insurer and its representatives to obtain medical, billing and employment records as necessary to determine eligibility for PIP benefits and to coordinate benefits with other sources. I understand that false statements made to obtain benefits may result in denial of benefits and may be subject to civil or criminal penalties, including rescission of coverage.

Additional Remarks / Special Instructions

Applicant Printed Name:

Signature:

Date:

What the Insurance PIP Choice Form Is

The Insurance PIP Choice Form documents a policyholder’s election regarding Personal Injury Protection (PIP) coverage under an auto insurance policy. It records whether the insured accepts, rejects, or limits PIP benefits and captures identifying policy details, effective dates, and signatures used by insurers, claims teams, and medical providers during claims intake and billing.

Why a Clear PIP Choice Form Matters

A completed PIP Choice Form creates an auditable record of coverage elections, helps avoid billing disputes, and signals informed consent. It supports accurate claims handling and may be required by the insurer or state law to validate a waiver or election.

Who Typically Completes and Receives This Form

The form is completed by insured drivers or their authorized representatives when selecting or declining PIP coverage or when submitting related claims.

Policyholders and drivers — sign to accept or decline PIP coverage and confirm identity.
Insurance agents and carriers — track elections, file with the policy record, and use for claims processing.
Medical providers and billing teams — rely on the form to establish payer responsibility and comply with treatment authorizations.

Keep a signed copy in the policy file and share the completed form with any party that will bill or process PIP-related claims.

Essential Sections to Include in a Professional PIP Choice Form

A complete form groups policy identification, the coverage election, timing, signature evidence, and any required state disclosures so parties can confirm the election and process claims correctly.

Policy Details

Policy number, insurer name, named insured, and contact information for accurate matching with claims and billing.

Coverage Election

A clear checkbox or selection for Accept PIP, Decline PIP, or Limited PIP with precise language to show the insured’s intent.

Effective Date

The date the election takes effect, entered as MM/DD/YYYY, which determines when the choice applies to claims.

Acknowledgments

Consumer disclosures required for certain transactions and an explicit statement that the insured understands the election and its consequences.

Signature Block

Signature, printed name, signer role (insured/agent), and date; electronic signatures must meet ESIGN/UETA criteria.

Recordkeeping

Space for insurer use: receipt date, processing agent, and internal reference number to support audit trails.

Step-by-Step: Filling Out the Form

Follow these steps in order to ensure the election is clear, attributable, and retained for claims and audits.

01

Gather documents: Collect policy ID, driver info, and vehicle VIN before you start.
02

Choose election: Select the correct PIP option and complete any required disclosures.
03

Sign and date: Sign in the signature block and add the date in MM/DD/YYYY format.
04

Submit to insurer: Send via insurer portal, email, or certified mail per carrier instruction.

From Completion to Claim Processing

After signature, the form moves through verification, file attachment, and claim-processing stages; retain an electronic copy for audit purposes.

Upload: Submit the completed form to the carrier’s claims portal or document inbox.
Verify: Insurer confirms policy match, signature, and effective date before applying election.
Attach: Carrier attaches the form to the policy and claim file for billing reference.
Retain: Maintain a copy per retention rules and include the audit trail.

Recommended Digital Workflow Settings

Configure your electronic workflow to capture identity, retain evidence, and notify stakeholders automatically.

Field	Configuration
Signer Authentication	Use email plus SMS code or two-factor for stronger attribution.
Email Notifications	Enable automatic confirmations to signer and insurer contact.
Storage Location	Save signed copies to the policy document library with versioning.
Auto-Reminders	Set reminders for unsigned forms after defined intervals.

Digital Submission and Integration Considerations

Choose a platform that supports secure uploads, identity verification, and integration with your policy administration system.

Integrations: Salesforce, NetSuite, Microsoft 365, and Google Workspace integrations reduce manual entry.
Formats: Accept PDF and DOCX; preserve original layout for audit.
Authentication: Support email, SMS, and advanced signer authentication where required.

Ensure platform encryption, audit trails, and role-based access control are enabled to meet insurer and regulatory expectations.

Timing: When to Complete and Submit the Form

Timelines vary by carrier and state. Complete the form at policy purchase, renewal, or at the start of any claim that may invoke PIP benefits.

At policy purchase:

Complete the election when buying or modifying an auto policy to set coverage expectations.

At renewal:

Confirm or re-elect PIP options during policy renewal to update coverage terms.

When filing a claim:

Provide the form early in the claims process if treatment or billing depends on PIP.

Before treatment:

If declining PIP, document the election before care begins to prevent billing disputes.

Insurer deadlines:

Adhere to any carrier-specific submission deadlines; check the insurer’s guidance.

Key Milestones From Election to Record Closure

Track these sequential milestones to ensure the election is applied, processed, and retained for audits.

01

Election Recorded

Form is received and entered into the policy record.

02

Verification Complete

Carrier confirms identity, policy match, and effective date.

03

Applied to Claims

Election is used to determine payer responsibility for related claims.

04

Retention & Audit

Finalize file retention and retain audit trail for regulatory review.

Common Pitfalls to Avoid When Preparing the Form

Submitting an unsigned or undated form which can delay claims processing and create uncertainty about the insured’s intent.
Entering names or policy numbers that do not match the insurer’s records, causing mismatches and manual rework.
Selecting more than one PIP option or ambiguous language, producing conflicting elections that insurers must resolve.
Failing to retain a copy and audit trail, leaving providers and carriers without evidence during audits or disputes.

Potential Consequences of an Incorrect or Missing Form

Loss of PIP Benefits: Selected waiver may remove entitlement to PIP payments.

Claim Denial: Incomplete forms can trigger denials or delays.

Billing Disputes: Providers may be billed incorrectly without clear election.

Regulatory Scrutiny: Insurer errors can invite state regulator review.

Financial Liability: Insureds could face out-of-pocket treatment costs.

Administrative Costs: Correcting mistakes increases processing time and expense.

Security and Compliance Considerations

Encryption: TLS 1.2/1.3 in transit; AES-256 at rest.

Audit Trail: Timestamps, IP address, and action history retained.

HIPAA Support: HIPAA compliance available; BAA required for PHI.

ESIGN / UETA: Electronic signatures accepted under ESIGN and UETA.

Access Controls: Role-based permissions and SSO integration available.

Certifications: SOC 2 Type II and ISO 27001 certifications supported.

eSignature Vendor Pricing and Feature Comparison

Common eSignature vendors vary by price model and capabilities; signNow is listed first for direct feature comparison across entry-level and enterprise plans.

	signNow	DocuSign	Adobe Sign	PandaDoc	HelloSign
Starting Price	$8/user/mo	$15/user/mo	$14/user/mo	$19/user/mo	$15/user/mo
Free Trial	7-day free trial	Varies by vendor	Varies by vendor	Varies by vendor	Varies by vendor
Bulk Send	Yes (Business Premium)	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Varies by plan	Varies by plan	Varies by plan	Varies by plan
Envelope Cap	No cap	100 envelopes/user/year	Varies	Varies	Varies

Frequently Asked Questions About the PIP Choice Form

Answers to common execution, validity, and processing questions to help claim handlers, insureds, and providers avoid delays and disputes.

Need help? Contact support

Can this form be signed electronically?
Yes. Electronic signatures generally satisfy legal requirements under the ESIGN Act (15 U.S.C. ch. 96) and UETA where adopted, provided intent, consent, attribution, and retention are demonstrable.
Does the form ever require notarization?
Most carriers do not require notarization for PIP elections, but state rules or insurer-specific requirements can differ. Confirm with the insurer or state regulator before notarizing.
What if the name or policy number is incorrect?
Errors can cause claim delays. Correct the form promptly and provide a signed amendment or an insurer-approved replacement to ensure the election is applied.
How do I revoke or change an election?
Changes require a clear written amendment or new election accepted by the insurer; follow carrier procedures and retain both records. Legal consequences may vary by state and carrier.
What supporting documents should accompany the form?
Provide policy declarations, proof of identity, and vehicle information; include medical releases only if required and ensure HIPAA protections for PHI.
How long before the insurer applies the election?
Processing times vary by carrier and intake channel; digital submissions with complete data and authentication typically process faster than mailed forms.

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