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New Jersey Property-Liability Insurance Guaranty Association
New Jersey Surplus Lines Insurance Guaranty Fund
Unsatisfied Claim and Judgment Fund
Workers’ Compensation Security Fund
Basking Ridge, New Jersey 07920
Tel: (908) 382-7100
www.njguaranty.org
CONDITIONAL ASSIGNMENT OF PERSONAL INJURY PROTECTION BENEFITS &
DISCLOSURE REQUIREMENTS (hereinafter “Conditional Assignment”)
Claimant: __________________ Date of Accident: _______________ Claim Number: _______________
PLEASE READ CAREFULLY AS THIS ASSIGNMENT IMPOSES DUTIES AND OBLIGATIONS UPON
THE PERSON(S) AND/OR THE ENTITIES WHO SIGN IT
Under your personal injury protection (“PIP”) coverage, the New Jersey Property-Liability Insurance Guaranty Association
(“NJPLIGA”) can reimburse you directly for covered expenses. However, if you are being presented with this form, your doctor or
other health care provider is asking that your benefits be "assigned" to them so that NJPLIGA may instead pay your provider directly.
If you choose to assign your benefits to your doctor or other health care provider, you no longer have the right to file any claim,
lawsuit or arbitration against NJPLIGA seeking reimbursement for those benefits. Nothing in this Conditional Assignment authorizes
the doctor or other health care provider and/or its agents to pursue a claim for bodily injuries on a patient or claimant’s behalf.
BY CLAIMANT: By signing this Conditional Assignment below, I _________________________________________________,
(Please Print - Name of Claimant/Patient)
hereby assign my right to pursue a claim for reimbursement of PIP benefits under the applicable insurance policy or pursuant to the
Unsatisfied Claim and Judgment Fund (“UCJF”), N.J.S.A. 39:6-60 et seq., to the doctor or other health care provider (his/her
employees, designees, and/or assignees) that has executed this Assignment. This Assignment is expressly contingent upon the doctor
or other health care provider agreeing to the terms set forth herein. I acknowledge that the doctor or other health care provider’s failure
to honor the obligations set forth below may render this Conditional Assignment null and void. Furthermore, I authorize the release of
medical records to NJPLIGA. A photocopy of this document shall be considered as effective and valid as the original.
BY PROVIDER: By signing this Conditional Assignment below, I _________________________________________, on behalf of:
(Please Print – Name of Provider/Authorized Representative)
_______________________________________________________________________________________________________,
(Please Print – Name of Provider)
assert that I am a representative of the health care provider noted above with the authority to bind the provider to the terms as set forth
in this Assignment. I have read the information contained in NJPLIGA’s Decision Point Review Plan (“DPR Plan”), NJPLIGA’s
information letter concerning its DPR Plan and this Assignment. As a condition precedent to NJPLIGA’s accepting this assignment of
benefits, on behalf of the doctor or other health care provider noted above individually, and on behalf of all medical staff associated
with the provider, we collectively understand and agree to abide by the following:
1. To obtain a fully executed Conditional Assignment in order to be paid directly by NJPLIGA for covered services. NJPLIGA’s
CONDITIONAL ASSIGNMENT OF PERSONAL INJURY PROTECTION BENEFITS & DISCLOSURE REQUIREMENTS
form is the only valid assignment of benefits. A fully executed copy of this Conditional Assignment must be furnished to
NJPLIGA upon request.
2. That the Conditional Assignment must be signed by the claimant and the treating health care provider or an agent authorized to
act on behalf of the provider. By executing the Conditional Assignment, or having it executed, the treating health care provider
agrees to be bound by the terms of the Assignment and other applicable terms, conditions and duties as set forth in all applicable
statutes, rules, regulations and NJPLIGA’s DPR Plan. The treating health care provider agrees that NJPLIGA has the right to
reject, terminate or revoke the Conditional Assignment at any time.