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.
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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.
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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.
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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.
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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.
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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.
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PIP Application |
Form made in support of a claim. Must be fully completed and
submitted to the Association.
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Affidavit of No Insurance |
Sworn statement made in support of a claim. Must be fully
completed, notarized and submitted to the Association.
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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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HIPAA Privacy Authorization |
Authorization for use or disclosure of protected health information
pursuant to the Health Insurance Portability and Accountability Act.
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