Fillable Personal Injury Protection (Plymouth Rock Assurance)

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Personal Injury Protection (Plymouth Rock Assurance)

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Application for Benefits:
Personal Injury Protection
CLAIM NUMBER
(12-digit number)
To enable us to determine if you are entitled to benefits under the Massachusetts Personal Injury
Protection Law, please complete this form and return it promptly to the address provided at the
end of this form.
YOUR PERSONAL INFORMATION
First Name: Last Name:
Date of Birth: / / Social Security Number: – –
Street Address: City: State: Zip Code:
Home Phone: ( ) – Work Phone: ( ) – Cell Phone: ( ) –
ACCIDENT & INJURY INFORMATION
Date of Accident: / / Time of Accident: :
¡
am
¡
pm
Street Address Where Accident Occurred: City: State:
Brief Description of Accident
At the time of the accident,
were you the driver of our policyholder’s car?
¡
Yes
¡
No
were you a passenger in our policyholder’s car?
¡
Yes
¡
No
were you a pedestrian?
¡
Yes
¡
No
were you a member of our policyholder’s household?
¡
Yes
¡
No
Form continues
To complete this form by hand:
1 Print all pages of the form.
2 Complete the form by filling in each space with black or blue
ink. Do not use pencil.
3 When finished, mail the form to Plymouth Rock’s Claims
Department at the address provided at the bottom of
the form.
To complete this form electronically:
1 Save this writable PDF to your computer, then open it using
Adobe’s Acrobat Reader.
2 Complete the form by typing in each field and/or checking
the appropriate buttons. Tip: you can tab from field to field.
3 When finished, save and print the form. Then mail the form to
Plymouth Rock’s Claims Department at the address provided
at the end of the form.
Or
Complete this form to the best of your knowledge and belief. DO NOT GUESS at any answers. If you don’t know the
answer to a question, leave that field blank. Please call your Claim Representative if you need help.
?
As a result of this accident, were you injured?
¡
Yes
¡
No
IF YES, complete the remaining questions below and the form on the next page.
IF NO, sign directly below and return this questionnaire.
✘
/ /
Signature (Sign here only if you were NOT injured in the accident.) Date
Describe Your Injury
Were you treated by a doctor?
¡
Yes
¡
No
IF YES, Doctor’s First Name:
Doctor’s Last Name:
Street Address: City: State: Zip Code:
IF TREATED IN A HOSPITAL, were you:
¡
In-Patient
¡
Out-Patient
Amount of medical bills to date: $
Will you have more medical expenses?
¡
Yes
¡
No
At the time of the accident, were you on company business?
¡
Yes
¡
No
Your Health Insurance Company: Policy Number:
As a result of your injury, have you had any expenses that would be considered out of the ordinary?
¡
Yes
¡
No
IF YES, please explain:
WAGE & EMPLOYMENT INFORMATION
Did you lose wages or salary as a result of your injury?
¡
Yes
¡
No
IF YES, amount lost to date: $
What is your average weekly wage or salary? $
IF YOU LOST WAGES: date disability from work began: / / Date you returned to work: / /
Are you eligible for payments under any wage or salary continuation plan?
¡
Yes
¡
No
IF YES, amount: $
¡
Per Week
¡
Per Month
List Names and Addresses of Your Employer(s) for One Year Prior to the Accident
1
Employer: From: / To: /
Street Address: City: State: Zip Code:
2
Employer: From: / To: /
Street Address: City: State: Zip Code:
3
Employer: From: / To: /
Street Address: City: State: Zip Code:
IMPORTANT: To be eligible for benefits, you must complete, sign, and return this application.
✘
/ /
Signature Date
Application for Benefits: Personal Injury Protection (continued)
Additional form on next page
Health Insurance Affidavit
CLAIM NUMBER
(12-digit number)
In accordance with Chapter 273 of the Acts of 1988, insurance companies are required to obtain information
regarding other health benefits (HMO, Medicare, health insurance, etc.) available to you before they can
process your claim for Personal Injury Protection Benefits.
IF YOU DO NOT have health insurance of your own, or benefits available through a household member,
please skip to Section Three (next page). PLEASE NOTE that if you do not have health insurance of
your own, or benefits available through a household member, your signature must be notarized.
SECTION ONE: Benefits Information
To be completed if you have health benefits available to you.
First Name of Insured: Last Name of Insured:
Health Insurance Company: Policy Number:
Policyholder’s First & Last Name: (If different than name of insured)
Deductible Amount: $ and/or Co-Insurance: (Amount paid by you) $
✘
/ /
Policyholder Signature
Date
SECTION TWO: Additional Benefits Information
To be completed in addition to Section One, if you are entitled to other health benefits through
any other policy (i.e., spouse, parent, legal guardian).
Health Insurance Company: Policy Number:
Policyholder’s First & Last Name: Relationship: (i.e., Spouse, Parent, Legal Guardian)
Deductible Amount: $ and/or Co-Insurance: (Amount paid by you) $
✘
/ /
Policyholder Signature
Date
Form continues
To complete this form by hand:
1 Print all pages of the form.
2 Complete the form by filling in each space with black or blue
ink. Do not use pencil.
3 When finished, have your signature notarized before mailing
the form to Plymouth Rock’s Claims Department at the
address provided at the end of the form.
To complete this form electronically:
1 Save this writable PDF to your computer, then open it using
Adobe’s Acrobat Reader.
2 Complete the form by typing in each field and/or checking
the appropriate buttons. Tip: you can tab from field to field.
3 When finished, save and print the form and have your signature
notarized before mailing the form to Plymouth Rock’s Claims
Department at the address provided at the end of the form.
Or
Complete this form to the best of your knowledge and belief. DO NOT GUESS at any answers. If you don’t know the
answer to a question, leave that field blank. Please call your Claim Representative if you need help.
?
SECTION THREE
I certify that I do not have any accident and/or health benefits available to me through either my own policy
or that of a household member.
✘
/ /
Policyholder Signature (To be signed in the presence of a Notary Public.)
Date
Health Insurance Affidavit (continued)
Additional form on next page
YOUR SIGNATURE MUST BE NOTARIZED.
Please bring this form to a Notary Public. Sign on the line above in their presence and have your signature notarized.
State of: County of:
On this day of , 201 , before me, the undersigned notary public, personally appeared
, proved to me through satisfactory evidence of identity, being in this
instance , and acknowledged to me that he/she signed the foregoing
voluntarily and for its stated purpose.
Notary Public Signature:
✘
My Commission Expires: / /
HIPAA Compliant Authorization for the Release of Patient Information
Pursuant to 45 CFR 164.508
CLAIM NUMBER
(12-digit number)
TO
Name of Healthcare Provider / Physician / Facility / Medicare Contractor:
Street Address: City: State: Zip Code:
Patient’s First Name: Patient’s Last Name:
Date of Birth: / / Social Security Number: – –
I authorize and request the disclosure of all protected information for the purpose of review and evaluation in connection with a legal claim. I expressly request
that the designated record custodian of all covered entities under HIPAA identified above disclose full and complete protected medical information including
the following: All medical records, meaning every page in my record, including but not limited to: office notes, face sheets, history and physical, consultation
notes, inpatient, outpatient and emergency room treatment, all clinical charts, reports, order sheets, progress notes, nurse’s notes, social worker records,
clinic records, treatment plans, admission records, discharge summaries, requests for and reports of consultations, documents, correspondence, test results,
statements, questionnaires/histories, correspondence, photographs, videotapes, telephone messages, and records received by other medical providers. All
physical, occupational and rehab requests, consultations and progress notes. All disability, Medicaid or Medicare records including claim forms and record
of denial of benefits. All employment, personnel or wage records. All autopsy, laboratory, histology, cytology, pathology, immunohistochemistry records and
specimens; radiology records and films including CT scan, MRI, MRA, EMG, bone scan, myleogram; nerve conduction study, echocardiogram and cardiac
catheterization results, videos/CDs/films/reels and reports. All pharmacy/prescription records including NDC numbers and drug information handouts/
monographs. All billing records including all statements, insurance claim forms, itemized bills, and records of billing to third party payers and payment or
denial of benefits for the period (date of loss) / / to (present date) / / . I understand the information to be released or disclosed
may include information relating to sexually transmitted diseases, acquired immunodeficiency syndrome (AIDS), or human immunodeficiency virus (HIV),
and alcohol and drug abuse. I authorize the release or disclosure of this type of information. This protected health information is disclosed for the following
purposes: Automobile claim disposition.
This authorization is given in compliance with the federal consent requirements for release of alcohol or substance abuse records of 42 CFR 2.31, the
restrictions of which have been specifically considered and expressly waived. You are authorized to release the above records to the following representatives
of defendants in the above-entitled matter who have agreed to pay reasonable charges made by you to supply copies of such records:
To be completed by an authorized representative of Plymouth Rock Assurance
Adjuster’s Name: Name of Representative:
Representative Capacity: (e.g., Attorney, Records Requestor, Agent, etc.)
Street Address: City: State: Zip Code:
I understand the following:
See 45 CFR §164.508(c)(2)(i-iii)
a. I have a right to revoke this authorization in writing at any time, except to the extent information has been released in reliance upon this authorization.
b. The information released in response to this authorization may be re-disclosed to other parties.
c. My treatment or payment for my treatment cannot be conditioned on the signing of this authorization. Any facsimile, copy or photocopy of the authorization
shall authorize you to release the records requested herein. This authorization shall be in force and effect until two years from date of execution at which time
this authorization expires.
✘
/ /
Signature of Patient or Legally Authorized Representative (See 45 CFR § 164.508(c)(1)(vi)) Date
Name of Legally Authorized Representative (See 45 CFR § 164.508(c)(1)(vi)) Relationship
✘
/ /
Witness Signature Date
Additional form on next page
CLAIM NUMBER
(12-digit number)
This authorization, or photocopy hereof, will authorize you to furnish all information you may have regarding
my wages or salary while employed by you. You are authorized to provide this information.
WAGE & EMPLOYMENT INFORMATION
Have you lost wages or salary as a result of your injury?
¡
Yes
¡
No
Have you received or are you eligible for payment under any wage or salary continuation plan?
¡
Yes
¡
No
IF YES, amount: $
¡
Per Week
¡
Per Month
List Names and Addresses of Your Employer(s) for One Year Prior to the Accident
1
Employer: From: / To: /
Street Address: City: State: Zip Code:
2
Employer: From: / To: /
Street Address: City: State: Zip Code:
3
Employer: From: / To: /
Street Address: City: State: Zip Code:
✘
/ /
Signature Date
Authorization for
Wage and Salary Information
Claims Department
Plymouth Rock Assurance Corporation, PO Box 9112, Boston, MA 02112-9112
Return This
Form To
Thank you.
All Rights Reserved ©2012 Rev_02_12
To complete this form by hand:
1 Print all pages of the form.
2 Complete the form by filling in each space with black or blue
ink. Do not use pencil.
3 When finished, mail the form to Plymouth Rock’s Claims
Department at the address provided at the bottom of
the form.
To complete this form electronically:
1 Save this writable PDF to your computer, then open it using
Adobe’s Acrobat Reader.
2 Complete the form by typing in each field and/or checking
the appropriate buttons. Tip: you can tab from field to field.
3 When finished, save and print the form. Then mail the form to
Plymouth Rock’s Claims Department at the address provided
at the end of the form.
Or
Complete this form to the best of your knowledge and belief. DO NOT GUESS at any answers. If you don’t know the
answer to a question, leave that field blank. Please call your Claim Representative if you need help.
?
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Personal Injury Protection (Plymouth Rock Assurance)

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Completed 3 August 2021

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