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Excess Medical Benefits ( EMB ) Forms


Form Name Description Format
First Notice Download and complete this form to report an EMB claim whenever medical expense benefits of $50,000 or more have been paid for personal injury to one person for one accident and/or your potential exposure exceeds $75,000.
Reimbursement and Reserve Download and complete this "RR" form to request reimbursement and provide advice as to the reserve requirements on individual claims. The RR form must be accompanied by the EMB Payment Record, below.
EMB Payment Record Download and complete this form to provide your accounting of medical benefits incurred and paid. Please note that bills for providers in excess of $10,000 must be accompanied by an audit report and bills for facilities must be accompanied by on on-site audit report or they are subject to a 20% penalty.
Recovery Certification Download and complete this form with the First Notice or RR form. Your signature confirms that you have investigated all potential recovery sources including subrogation against culpable third parties.
PIP Coverage Selection Download and complete this form and submit it with the First Notice. Your signature confirms that the injured party is afforded PIP benefits under your policy of insurance. There may be concurrent PIP coverage with other carriers that need to be investigated.


Uninsured Motorist Forms


Form Name Description Format
Notice of Intention to Make Claim Written notice to the Association that a claim may be made as required under N.J.S.A. 39:6-65. Separate notice must be filed on behalf of each claimant.
PIP Application Form made in support of a claim. Must be fully completed and submitted to the Association.
Affidavit of No Insurance Sworn statement made in support of a claim. Must be fully completed, notarized and submitted to the Association.
Certificate of Medicare Eligibility Sworn statement made in support of a claim. Must be fully completed and submitted to the Association.



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