APPLICATION FOR BENEFITS PERSONAL INJURY …

1 APPLICATION FOR BENEFITS PERSONAL INJURY PROTECTIONIMPORTANT:1. TO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE PERSONAL INJURYPROTECTION LAW, YOU MUST COMPLETE AND SIGNTHIS YOU MUST ALSO SIGNTHE ATTACHED AUTHORIZATION(S).3. RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE RECEIVED TO NAMEYOUR ADDRESS (NO., STREET, CITY OR TOWN, STATE AND ZIP CODE)PLACE OF ACCIDENT (STREET, CITY OR TOWN AND STATE)DATE AND TIME OF ACCIDENT//BRIEF DESCRIPTION OF ACCIDENTWERE YOU THE DRIVER OF THE AUTOMOBILE?YES NO WERE YOU A PASSENGER IN THE AUTOMOBILE?

2 YES NO WERE YOU A PEDESTRIAN?YES NO WERE YOU A MEMBER OF THE AUTOMOBILE OWNER S HOUSEHOLD? YES NO DESCRIBE ALL AUTOMOBILES OWNED BY YOU OR ANY MEMBER OF YOUR FAMILY THAT RESIDED IN YOUR HOUSEHOLD AS OF THE DATE OFTHE LOSS. AUTOMOBILEOWNERINSURANCE NUMBER_____DATE OF BIRTH SOCIAL SECURITY POLICYHOLDERDATE OF ACCIDENTFILE NUMBERTO:CURE214 CARNEGIE CENTER, SUITE 101 PRINCETON, NJ :DATE:DESCRIBE YOUR INJURYWERE YOU TREATED BY A DOCTOR?YES NO IF YOU WERE TREATED IN A HOSPITAL WERE YOUAN IN-PATIENT? OUT-PATIENT?

3 AMOUNTOF MEDICALBILLS TO DATE: $DID YOU LOSE WAGES OR SALARYAS ARESULTOF YOUR INJURY ? YES NO IF YOU LOST WAGES:HAVE YOU RECEIVED OR ARE YOU ELIGIBLE FORIF YES, AMOUNTBENEFITS UNDER$LISTNAMES AND ADDRESSES OF YOUR EMPLOYER AND OTHER EMPLOYERS FOR ONE YEAR PRIOR TO ACCIDENT DATE AND GIVE OCCUPATION AND DATES OF EMPLOYMENT:YESNO(1) ANYWORKMEN S COMPENSATION LAW?(2) EMPLOYEES TEMPORARY DISABILITY BENEFIT STATUTE?(3) MEDICARE?DATE DISABILITYDATE YOU RETURNEDFROM WORK BEGANTO WORKIF YES, AMOUNTLOST TO DATE $WHAT IS YOUR AVERAGEWEEKLY WAGE OR SALARY?

4 $WILL YOU HAVE MORE MEDICALEXPENSE? YES NO AT TIME OF YOUR ACCIDENT WERE YOU IN THECOURSE OF YOUR EMPLOYMENT? YES NO HOSPITAL S NAME AND ADDRESSDOCTOR S NAME AND ADDRESSPER WEEK PER MONTHEMPLOYER AND ADDRESSOCCUPATIONFROMTOEMPLOYER AND ADDRESSOCCUPATIONFROMTOEMPLOYER AND ADDRESSOCCUPATIONFROMTOAS ARESULTOF YOUR INJURYHAVE YOU HAD ANY OTHER EXPENSES? YES NO IF YES, EXPLAIN ON REVERSE PERSON WHO KNOWINGLY FILES A STATEMENT OF CLAIM CONTAINING ANY FALSE OR MISLEADING INFORMATION IS SUBJECT TOCRIMINAL AND CIVIL :SIGNATURE:DATE:DATE:A 3965A(1-95)AUTHORIZATION FOR MEDICAL INFORMATIONTHIS AUTHORIZATION OR PHOTOCOPY HEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION WHILE UNDER YOUROBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED, X-RAY AND PHYSICAL FINDINGS DIAGNOSIS AND PROGNOSIS.

5 YOU ARE AUTHORIZED TO PROVIDETHIS INFORMATION IN ACCORDANCE WITH THE PERSONAL INJURY protection BENEFITS :SIGNATURE:DATE:AUTHORIZATION FOR WAGE AND SALARY INFORMATIONTHIS AUTHORIZATION OR PHOTOCOPY HEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY WAGES OR SALARY WHILEEMPLOYED BY YOU. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE PERSONAL INJURY protection BENEFITS :AUTHORIZATION TO EXTEND TIME TO SCHEDULE A PHYSICAL EXAMINATION FOR DECISION POINT REVIEW(OPTIONAL)TO ASSURE MY ABILITY TO ATTEND THE REQUIRED PHYSICAL EXAMINATION, I HEREBY AUTHORIZE CURE TO TAKE UP TO 14 DAYS AFTER RECEIPT OF NOTICE FROMMY HEALTH CARE PROVIDER (RATHER THAN THE 7 DAYS NORMALLY REQUIRED)

6 FOR SCHEDULING A PHYSICAL EXAMINATION IF ONE IS NEEDED IN ORDER TO MAKEA DETERMINATION REGARDING THE MEDICAL NECESSITY OF TESTS OR TREATMENTS UNDER THE CURE DECISION POINT REVIEW YOU HAVE HEALTH insurance ON THE DATE OF LOSS? YES NOIF YES, PROVIDE THE INFORMATION REQUESTED BELOW REGARDING YOUR HEALTH INSURER(S):1. NAME: _____ 2. NAME: _____ADDRESS: _____ ADDRESS: _____PHONE:_____ PHONE:_____FAX#:_____ FAX#: _____E-MAIL: _____ E-MAIL: _____POLICY/GROUP #/CERTIFICATE #: _____ POLICY/GROUP#/CERTIFICATE #:_____WERE YOU INJURED AS A RESULT OF THIS ACCIDENT?

7 YES NO IF YOUR ANSWER IS YES, COMPLETE THE REST OF THIS FORM. IF NO, SIGN HERE AND RETURN THIS FORM TO YOU OR ANY MEMBER OF YOUR HOUSEHOLD OWN AN AUTOMOBILE? YES NO 12/1/10 12:33 PM Page 1