No-fault automobile insurance personal injury protection claim forms

Issued and entered March 27, 1984 by Nancy A. Baerwaldt, Commissioner of Insurance

I. BACKGROUND

The Michigan no-fault automobile insurance law took effect in October 1973. In April 1973, the Insurance Bureau issued guidelines to implement the no-fault law. These guidelines included an Application for Benefits form, an Attending Physician's Report form, and a Wage and Salary Verification form which insurers were required to use in connection with personal protection insurance claims.

The Insurance Bureau has received comments and suggestions concerning the need to update these forms to reflect actual claims experience under the law. With the help of a committee made up of representatives of trial lawyers and insurance companies, the Insurance Bureau has revised the personal injury protection claim forms.

II. FORMS WITH INSTRUCTIONS

Attached are the revised Application for Benefits forms, the revised Attending Physician's Report form, and the revised Wage and Salary Verification form. These forms replace the forms issued in the Insurance Bureau's April 1973 no-fault automobile insurance guidelines. Insurance companies should begin using the revised forms as soon as possible and in no case later than July 15, 1984.

Questions concerning the revised forms should be directed to:

Ms. Teri Creamer
Michigan Insurance Bureau
P.O. Box 30220
Lansing, MI 48909
(517) 373-2984