Standard Coverage Selection Form(20 KB PDF)

Fax and Return to Member Services at 877.664.8233
This is not an application for insurance.
Please contact New Member Services at 800.535.CURE (2873) if you are interested in applying.

Basic Coverage Selection Form (17 KB PDF)

Fax and Return to Member Services at 877.664.8233
This is not an application for insurance.
Please contact New Member Services at 800.535.CURE (2873) if you are interested in applying.

New Jersey Driver's Report of Accident (80 KB PDF)

Fax and Return Claims at 609.520.0030

Application for PIP Benefits (140 KB PDF)

Note: This document should be printed on legal size paper (8.5" x 14")
Fax and Return to the PIP Department at 609.520.0097

Attending Physician's Report (61 KB PDF)

Fax and Return to the PIP Department at 609.520.0097

Affidavit of No Insurance (35 KB PDF)

Fax and Return to the PIP Department at 609.520.0097

New Jersey Auto Insurance Buyer's Guide (847 KB PDF)

*** Updated March 2013 ***
Decision Point Review Plan Notice for Insureds and Providers (80 KB PDF)

Attending Provider Treatment Plan Form (20 KB PDF)

Fax and Return to the PIP Department at 609.520.0097

Tort Option Notice (56 KB PDF)

Fax and Return to Member Services at 877-664-8233.
This is not an application for insurance.
Please contact New Member Services at 800-535-CURE (2873) if you are interested in applying.

Physical Damage Selection Form (63 KB PDF)

Fax and Return to Member Services at 877-664-8233.
This is not an application for insurance.
Please contact New Member Services at 800-535-CURE (2873) if you are interested in applying.

Uninsured Motorist Coverage Options Form (54 KB PDF)

Fax and Return to Member Services at 877-664-8233.
This is not an application for insurance.
Please contact New Member Services at 800-535-CURE (2873) if you are interested in applying.

Underinsured Motorist Coverage Options Form (63 KB PDF)

Fax and Return to Member Services at 877-664-8233.
This is not an application for insurance.
Please contact New Member Services at 800-535-CURE (2873) if you are interested in applying.

Pennsylvania Driver's Report of Accident (84 KB PDF)

Fax and Return to Claims at 609-520-0030.

Witness Statement (49 KB PDF)

Fax and Return to Claims at 609-520-0030.

PA Application for Benefits (438 KB PDF)

Fax and Return to Claims at 609-520-0030.