UCJF Forms

Please be advised that knowingly filing a statement of claim containing any false, inaccurate or misleading information, or intentionally omitting information material to the claim, will result in the denial of benefits. Any person who knowingly files a statement of claim containing any false or misleading information may be subject to criminal and civil penalties.

Form

Description

  • Notice of Intention to Make Claim Written notice to the Association that a claim may be made as required under N.J.S.A. 39:6-65. Separate notice must be filed on behalf of each claimant.
  • PIP Application Form made in support of a claim. Must be fully completed and submitted to the Association.
  • Affidavit of No Insurance Sworn statement made in support of a claim. Must be fully completed, notarized and submitted to the Association.
  • Certificate of Medicare Eligibility Sworn statement made in support of a claim. Must be fully completed and submitted to the Association.
  • HIPAA Privacy Authorization Authorization for use or disclosure of protected health information pursuant to the Health Insurance Portability and Accountability Act.