ATTENDING PHYSICIAN S REPORT Date: Policy Holder: Date of Accident: TO ASSIST US IN DETERMINING BENEFITS DUE UNDER THE AUTOBOMILE PERSONAL INJURY PROTECTION LAW, THE ATTENDING PHYSICIAN MUST COMPLETE THIS REPORT AND RETURN IT DIRECTLY Phy 2025

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ATTENDING PHYSICIAN S REPORT Date: Policy Holder: Date of Accident: TO ASSIST US IN DETERMINING BENEFITS DUE UNDER THE AUTOBOMILE PERSONAL INJURY PROTECTION LAW, THE ATTENDING PHYSICIAN MUST COMPLETE THIS REPORT AND RETURN IT DIRECTLY Phy Preview on Page 1

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Personal injury protection (PIP), also known as no-fault insurance, covers medical expenses and lost wages for you and your passengers if youre injured in an accident.
Personal injury protection (PIP) insurance coverage includes payment for injury-related medical and rehabilitation expenses, loss of income, and funeral and burial expenses. Bodily injury liability coverage includes payment for any physical injuries that occur in an accident you cause.
The PIP statute requires automobile insurers to provide PIP benefits for the following: (1) to the named insured and members of his family residing in his household who sustained bodily injury while occupying, entering into, alighting from or using an automobile, or as a pedestrian, caused by an automobile or by an
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