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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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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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