Who must sign the form?

The claimant (or authorized representative) must sign; medical providers sign assignment-of-benefits sections when payment is redirected. If a minor is involved, a parent or legal guardian signs. Verify signatory authority to avoid processing delays.

Can the form be signed electronically?

Yes. Electronic signatures are enforceable under the ESIGN Act (15 U.S.C. ch. 96) and state UETA statutes when intent, consent, attribution, and record retention are documented. Confirm insurer acceptance and authentication level required.

What if medical records are needed?

Attach an authorization for release of medical information or include a HIPAA-compliant release. Healthcare data may be subject to HIPAA retention and handling requirements, so ensure secure transmission and a valid patient authorization.

My form was rejected for missing TIN — now what?

If a provider or payee TIN is missing or invalid, update the TIN on the form and resubmit. For payers, an incorrect TIN can trigger IRS backup withholding or information return issues.

Are notary or witness signatures required?

Most PIP/UM submission forms do not require notarization, but state-specific assignment language may. Check state rules where the loss occurred or the insurer’s instructions before notarizing.

How long before I receive payment?

Processing times vary by insurer and documentation completeness. Claims with complete medical billing and valid authorizations typically process faster; incomplete forms or authentication issues commonly extend timelines.

Electronic Signature
Templates
Miscellaneous
Insurance PIP & UM Form

Insurance PIP & UM Form

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

INSURANCE PIP & UM FORM

WHEREAS

WHEREAS the Insured has an automobile insurance policy issued by the Insurer and identified below, providing Personal Injury Protection (PIP) and Uninsured/Underinsured Motorist (UM) coverages subject to policy terms and applicable law; and

WHEREAS the Insured seeks to (a) notify the Insurer of a claim for PIP benefits, (b) elect or waive UM coverage and limits where permitted, and (c) authorize necessary releases for claims investigation and benefit payment.

WHEREAS the Insurer requires this completed form, together with supporting documentation, to process PIP benefits and to record any election or waiver of UM coverage in accordance with the policy and applicable statutes.

INSURED & POLICY INFORMATION

Insured Name Insured Date of Birth Mailing Address Phone Email Insurer / Company Name Policy Number Claim Number (if assigned)

ACCIDENT / LOSS DETAILS

Date of Loss: Time of Loss: Location:

Third Party / Other Vehicle Involved (if any) Police Report Number / Agency Description of Incident

PIP (PERSONAL INJURY PROTECTION) ELECTION / CLAIM

By checking the applicable box below, the Insured records the selection or claim regarding PIP benefits under the policy. The Insurer's payment of PIP benefits is subject to policy terms, deductible, and statutory offsets.

Elect PIP benefits under my policy PIP Coverage Limits (if elected) PIP Deductible (if applicable) Waive PIP benefits (I understand that waiver may affect available benefits)

PIP CLAIM / MEDICAL INFORMATION

List medical providers, treatment dates, and amounts claimed. Attach supporting bills and records as requested by the Insurer. By submitting these amounts the Insured certifies they are accurate to the best of their knowledge.

Primary Treating Provider Dates of Treatment Total Medical Expenses Claimed Lost Wages Claimed (if any) Scope and Nature of Injuries / Treatment Summary

UM (UNINSURED / UNDERINSURED MOTORIST) ELECTION / WAIVER

The Insured may elect or decline UM coverage in accordance with the policy and applicable law. Election or waiver recorded below will be applied prospectively in accordance with policy procedures.

Elect UM coverage UM Coverage Limits (if elected) Waive UM coverage (I acknowledge waiver may limit recovery against uninsured/underinsured motorists) If waiving UM, Insured Initials

AUTHORIZATION & RELEASE

The Insured authorizes any medical provider, employer, or other person having records or knowledge concerning the treatments, services, bills, and earnings of the Insured to release such information to the Insurer, its representatives, and third-party administrators for the purpose of claims investigation, evaluation, and payment. This authorization extends to physicians, hospitals, clinics, insurers, and governmental agencies to the extent permitted by law.

The Insured assigns to the Insurer, to the extent of benefits paid, the right to recover from any third party or their insurer for medical expenses and benefits paid on the Insured's behalf. The Insured agrees to cooperate in subrogation actions and to provide necessary documentation and signed statements as requested.

GOVERNING LAW & CERTIFICATION

This form and any claim adjudicated under it shall be governed by the law applicable to the policy and the state law where the policy was issued. By signing below, the Insured certifies under penalty of perjury that the information provided in this form is true, accurate, and complete to the best of the Insured's knowledge. False statements may be subject to civil or criminal penalties and may result in denial of benefits.

ACKNOWLEDGMENT

The Insured acknowledges receipt of a copy of this form after signing and recognizes that processing of benefits is subject to verification of coverage, coordination of benefits, and applicable subrogation rights.

Insured Printed Name:

Signature:

Date Signed:

What the Insurance PIP & UM Form Is and when it applies

The Insurance PIP & UM Form collects information needed to process Personal Injury Protection (PIP) and Uninsured/Underinsured Motorist (UM) claims after an automobile loss. Typical completed forms include claimant identity, policy and coverage details, accident date and location, medical provider and billing data, assignment of benefits where applicable, and signatures or authorizations for release of medical information. States vary on specific fields and authentication; privacy and retention rules can trigger HIPAA protections for health records. The form supports paper and electronic execution consistent with ESIGN and state UETA frameworks.

Quick sequential steps to complete the Insurance PIP & UM Form

Use this ordered checklist to prepare the form, verify details, and submit to the insurer or claims processor.

01

Gather Documents: Insurance card, medical bills, police report, and ID.
02

Enter Policy Info: Input policy number, effective dates, and carrier name.
03

Attach Medicals: Upload itemized bills, CPT codes, and ER notes if required.
04

Sign and Submit: Obtain signatures, then transmit form to the insurer or portal.

Frequently asked questions and common resolution steps

Answers to typical questions about signatures, missing data, HIPAA releases, and electronic submission for PIP and UM claims.

Need help? Contact support

Who must sign the form?
The claimant (or authorized representative) must sign; medical providers sign assignment-of-benefits sections when payment is redirected. If a minor is involved, a parent or legal guardian signs. Verify signatory authority to avoid processing delays.
Can the form be signed electronically?
Yes. Electronic signatures are enforceable under the ESIGN Act (15 U.S.C. ch. 96) and state UETA statutes when intent, consent, attribution, and record retention are documented. Confirm insurer acceptance and authentication level required.
What if medical records are needed?
Attach an authorization for release of medical information or include a HIPAA-compliant release. Healthcare data may be subject to HIPAA retention and handling requirements, so ensure secure transmission and a valid patient authorization.
My form was rejected for missing TIN — now what?
If a provider or payee TIN is missing or invalid, update the TIN on the form and resubmit. For payers, an incorrect TIN can trigger IRS backup withholding or information return issues.
Are notary or witness signatures required?
Most PIP/UM submission forms do not require notarization, but state-specific assignment language may. Check state rules where the loss occurred or the insurer’s instructions before notarizing.
How long before I receive payment?
Processing times vary by insurer and documentation completeness. Claims with complete medical billing and valid authorizations typically process faster; incomplete forms or authentication issues commonly extend timelines.

Primary users and stakeholders for the Insurance PIP & UM Form

Clear responsibilities and accurate field completion reduce follow-up requests and speed claim resolution.

Claimants and insured parties submitting medical or repair expenses for PIP or UM benefits.
Medical providers and billing services submitting claims or assignment-of-benefits documentation.
Insurance adjusters and third-party administrators reviewing coverage, liability, and payment responsibility.

Security, privacy, and compliance details for form handling

Encryption In Transit: TLS 1.2/1.3

Encryption At Rest: AES-256

Audit Trail: Tamper-evident logs

HIPAA Support: BAA available

Certifications: SOC 2 Type II

Accessibility: WCAG 2.0 AA

Consequences of errors or incomplete Insurance PIP & UM Forms

Claim Denial: Missing or incorrect data may trigger denial

Payment Delay: Incomplete documentation delays adjudication

Tax Impact: Incorrect TINs can trigger IRS action

Fraud Exposure: Material misstatements can lead to fraud investigation

Privacy Breach: Improper handling of PHI risks HIPAA penalties

Regulatory Fines: State insurance regulators may assess fines

Common preparation errors that cause processing delays

Incomplete provider identifiers: missing NPI or billing TIN often prevents electronic claim routing and can force manual rework and resubmission.
Incorrect policy or claim numbers: typographical errors in policy digits frequently misdirect claims and create duplicate files that take days to reconcile.
Unsigned releases or missing HIPAA authorizations: without valid patient authorizations, insurers may refuse to collect or review medical records needed for payment.
Misapplied assignment language: ambiguous or absent assignment-of-benefits clauses can prevent direct provider payment and require separate provider agreements.

Core sections commonly found on a professional PIP & UM form

Well-crafted forms group related data to speed review and reduce follow-up for carriers and providers.

Claimant Details

Full legal name, DOB, contact, and relationship to insured; used for identity verification and benefits delivery.

Policy Details

Insurer name, policy number, policy period, and named insured to confirm coverage and coordinate benefits across policies.

Accident Information

Date, time, location, police report number, and a brief narrative to support liability and coverage decisions.

Medical Billing

Itemized charges, CPT/ICD codes, provider NPI, and billing TIN required for payment adjudication under PIP or UM.

Assignment of Benefits

Legal language assigning claim payments to providers when permitted; state rules may govern enforceability.

Authorization & Signature

Consent for release of records, signatures with dates, and witness or notary fields when required by law or insurer.

Digital submission workflow overview

Typical eSubmission flows reduce paper handling and speed insurer receipt while preserving an audit trail.

Upload Document: Sender uploads completed PDF or template.
Place Fields: Add signature, date, and attachment fields as needed.
Authenticate Signer: Use email, SMS, or stronger methods for identity.
Transmit to Insurer: Send signed copy and audit trail to carrier or portal.

Recommended digital workflow settings for PIP & UM forms

Configure these settings to support secure intake, verification, and routing for claims.

Field	Configuration
Authentication Level	Email or SMS OTP; use stronger KBA for high-risk cases
Conditional Fields	Show assignment section only when provider payment desired
Attachment Handling	Require itemized bills and police report uploads
Recipient Routing	Auto-route to claims inbox and provider billing team

Technical considerations for secure eSubmission

Ensure the platform supports encryption, access controls, and retention features aligned with insurer and HIPAA requirements.

Document Formats: PDF/A, DOCX accepted; maintain original attachments
Integrations: Connectors for claims systems (e.g., CRM, ERP) help automate routing
Audit Trail: Preserve timestamp, IP, and action history for each signature

eSignature vendor pricing and capability snapshot for completing PIP & UM forms

Compare starting prices and key features relevant to high-volume claims workflows; signNow is listed first per vendor comparison rules.

	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 trial	Varies	Varies	Varies	Varies
Bulk Send	Yes	Yes	Yes	Yes	No
Audit Trail	Yes	Yes	Yes	Yes	Yes
HIPAA Compliant	Yes	Yes	Yes	No	No

Illustrative use cases from insurance and healthcare operations

Real-world scenarios show how accurate forms and eSignature reduce manual steps and speed payments.

Provider Assignment Example

A clinic submits PIP claims with assignment of benefits

Provider uses a completed assignment to bill the insurer directly
Resulting faster payment reduced AR days and cut manual follow-up for the clinic.

Insurer Intake Example

An insurer accepts e-signed UM forms through a portal

Claims team auto-routes documentation to adjusters based on coverage codes
Adjusters close straightforward claims more quickly with complete attachments and audit trails.

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