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PIP Application For Benefits
PIP Application For Benefits
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Form 1270F© 2004 Nationwide Publishing Company, Inc.http://www.claimspages.com.APPLICATION FOR BENEFITS—AUTO PERSONAL INJURY PROTECTIONInsurance Company ToClaims DeptTO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE AUTOMOBILE PERSONALINJURY PROTECTION LAW, PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY.ACCIDENT INFORMATIONName: Address:Phone Number: City, State, Zip:Date of Accident: Location of Accident:Description of Accident:.MEDICAL INFORMATIONWere you injured as a result of the accident? If yes, complete the rest...
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INFORME DEL MÉDICO TRATANTE Fecha: Titular de la póliza: Fecha del accidente: PARA AYUDARNOS A DETERMINAR LOS BENEFICIOS CORRESPONDIENTES A LA LEY DE PROTECCIÓN ANTE LESIONES PERSONALES POR ACCIDENTE AUTOMOVILÍSTICO, EL MÉDICO TRATANTE DEBE COMPLETAR EL PRESENTE INFORME Y ENVIÁRNOSLO DIRECTAMENTE Nombre del médico: Nombre del hospital...
Form 1220F © 2004 Nationwide Publishing Company, Inc. http://www.claimspages.com WAGE AND SALARY VERIFICATION DATE OUR POLICY HOLDER DATE OF ACCIDENT FILE NUMBER EMPLOYEE NAME: EMPLOYER NAME: ADDRESS: ADDRESS: CITY, STATE: CITY, STATE: ZIP CODE: ZIP CODE: SS#: SUPERVISOR: Dear Employer: The person named above has applied...
VERIFICACIÓN DEL SUELDO Y SALARIO FECHA TITULAR DE LA PÓLIZA FECHA DEL ACCIDENTE NÚMERO DE ARCHIVO NOMBRE DEL EMPLEADO: NOMBRE DEL EMPLEADOR: DIRECCIÓN: DIRECCIÓN: CIUDAD, ESTADO: CIUDAD, ESTADO: CÓDIGO POSTAL: CÓDIGO POSTAL: SEGURO SOCIAL Nº: SUPERVISOR: Estimado empleador: La persona mencionada anteriormente ha...
A form which is filled out by the attending physician in order to qualify for medical benefits under an automobile insurance policy.
A form which is filled out by the attending physician in order to qualify for medical benefits under an automobile insurance policy. (Spanish version of English form 3160F)
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