Personal Injury and Medical Payments Forms
State Farm® provides Personal Injury Protection (PIP) and/or Medical Payments Coverage (MPC) forms for your information. Talk to your claim associate about forms that may be needed for your claim.
Connecticut, Maine, New Hampshire, Rhode Island, and Vermont Medical Payments Coverage (MPC) Policyholders and Injured Parties
New Jersey Personal Injury Protection (PIP)
Forms to be Completed, Printed, Signed and Returned by the Injured Party
Policyholders, Injured Parties and Medical Providers
Claim Information Sheet — Basic Policy
Claim Information Sheet — Standard Policy
Attending Provider Treatment Plan
New Jersey PIP Pre-Service Approval Form
New Jersey PIP Post-Service Appeal Form
Claims with Date of Loss Prior to 11/1/2011
Medical Provider Package/Conditional Assignment of Benefits
Claims with Date of Loss On and After 11/1/2011
Medical Provider Package/Conditional Assignment of Benefits
Claims with Date of Loss On and After 12/15/2013
Medical Provider Package/Conditional Assignment of Benefits
Claims with Date of Loss On and After 12/1/2017
Medical Provider Package/Conditional Assignment of Benefits
Claims with Date of Loss On and After 9/1/2023
Medical Provider Package/Conditional Assignment of Benefits
PIP Vendor
New York Personal Injury Protection (PIP)
Policyholders and Injured Parties
NF-AOB Assignment of Benefits Form
NF-2 Application for Motor Vehicle No-Fault Benefits
NF-3 Verification of Treatment by Attending Physician or Other Provider of Health Service
NF-4 Verification of Hospital Treatment
NF-7 Verification of Self-Employment Income
NF-8 Agreement to Pursue Social Security Disability Benefits
NF-9 Agreement to Pursue Workers Compensation or N.Y.S. Disability Benefits
NF-11 Additional PIP Subrogation Agreement
NF-12 Lump-Sum Settlement Agreement
NF-13 Election of Option – Optional Basic Economic Loss Coverage