Insurance PIP Document

Insurance PIP Document

Applicant / Insured Information

Policy Details

PIP Coverage Selections

The undersigned elects the following Personal Injury Protection (PIP) benefits and acknowledges the coverage limits and deductibles stated. Selection of a coverage option authorizes payment to the insured or to a designated payee in accordance with policy terms.

Medical Expenses — Limit: $ Deductible: $

Lost Earnings / Wage Replacement — Limit: $ Waiting Period:

Funeral / Burial Expenses — Limit: $

Replacement Services (household services) — Limit: $

Attendant Care — Limit: $

Transportation / Mileage Reimbursement — Limit: $

Standard Exclusions and Acknowledgements

PIP benefits are subject to the terms, conditions, and exclusions of the policy. The insured acknowledges the following common exclusions and certifies understanding that benefits will not be payable when claims arise from these circumstances unless otherwise required by applicable statute.

Injuries intentionally caused by the insured or other covered persons are excluded.

Injuries sustained while operating a vehicle for commercial hire not specifically endorsed on the policy.

Injuries sustained while participating in speed contests, racing, or stunts.

Injuries for which benefits are payable under workers' compensation or similar laws; PIP may coordinate with such benefits.

Injuries occurring while the vehicle is used without the owner's permission or during the commission of a felony.

Beneficiary / Designated Payee for PIP Benefits

If Insured elects to have benefits paid to a designated payee, list the primary payee. Payments made to a designated payee are subject to policy provisions and any applicable assignment or subrogation rights.

Notice of Loss / Claim Intake (To be completed promptly after an incident)

Documentation Checklist (Attach copies)

Medical reports and treatment records

Itemized medical bills and invoices

Police or incident report

Witness statements or contact information

Photographs of scene or injuries

Other supporting documentation:

Declaration, Authorization, and Subrogation

By signing below, I certify under penalty of law that the information provided on this form is true and complete to the best of my knowledge. I authorize the insurer and its representatives to obtain medical records, billing statements, and other information necessary to evaluate and pay PIP benefits. I agree to cooperate with the insurer's investigation of any claim.

I acknowledge that payment of PIP benefits may be subject to coordination of benefits with other sources, including health plans, Medicare, or workers' compensation. I agree to reimburse the insurer from any recovery I obtain from third parties for medical or wage-loss benefits that the insurer has paid on my behalf (subrogation and right of reimbursement). The insurer may assert a lien against any third-party recovery to protect its rights to reimbursement.

I understand that providing false or misleading information or failing to disclose material facts may result in denial of benefits, cancellation of coverage, or other remedies permitted by law and the policy, including referral for criminal prosecution where appropriate.

Assignment of Benefits: I elect to assign PIP benefit payments to the treating provider or payee named above. I understand assignment does not expand coverage beyond policy terms.

Certification

I certify that I have read and understand the PIP coverage selections, exclusions, and the declaration above. I acknowledge that receipt of this document does not by itself guarantee payment of benefits; all payments are subject to policy provisions, limits, and applicable law.

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