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Excess Medical Benefits ( EMB ) Forms


Form NameDescriptionFormat
First NoticeDownload 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 ReserveDownload 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 RecordDownload 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 CertificationDownload 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 SelectionDownload 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 NameDescriptionFormat
Notice of Intention to Make ClaimWritten 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 ApplicationForm made in support of a claim. Must be fully completed and submitted to the Association.
Affidavit of No InsuranceSworn statement made in support of a claim. Must be fully completed, notarized and submitted to the Association.



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