Claim forms
Claim forms
To resolve your Plymouth Rock claim as quickly as possible, you may need to complete certain forms. Your claim representative is always happy to help by providing detailed instructions on what forms to complete, and how and where to submit them.
Claims forms
In New Hampshire, any motor vehicle accident causing death, personal injury or combined vehicle/property damage in excess of $1,000 must be reported to the Division of Motor Vehicles within 15 days. File a New Hampshire Motor Vehicle Accident Form (if necessary) using the NH Motor Vehicle Accident Report form. If you need any other forms related to your accident, please contact your claims representative.
Plymouth Rock Assurance
PO Box 900
Lincroft, NJ
07738
- Application for Benefits
- Affidavit of No Insurance
- Wage and Salary Verification Form
- Essential Services Form – Record of Service
- Essential Services Form – Service Restriction Checklist
- Health Carrier Information Form
- HIPAA Authorization Form
- Decision Point Review Plan 2017 Version
- Decision Point Review Plan 2022 Version
- Attending Provider Treatment Plan
- Surgical Pre-Certification Request Form
- Application for Benefits
- Affidavit of No Insurance
- Wage and Salary Verification Form
- Essential Services Form – Record of Service
- Essential Services Form – Service Restriction Checklist
- Health Carrier Information Form
- HIPAA Authorization Form
- Decision Point Review Plan 2017 Version
- Decision Point Review Plan 2022 Version
- Attending Provider Treatment Plan
- Surgical Pre-Certification Request Form
- Decision Point Review Plan 2017 Version
- Decision Point Review Plan 2022 Version
- Commercial Auto Decision Point Review Plan 2017 Version
- Commercial Auto Decision Point Review Plan 2022 Version
- Application for Benefits
- Affidavit of No Insurance
- Wage and Salary Verification Form
- Essential Services Form – Essential Services Form
- Essential Services Form – Service Restriction Checklist
- Health Carrier Information Form
- HIPAA Authorization Form
- Decision Point Review Plan 2017 Version
- Decision Point Review Plan 2022 Version
- Attending Provider Treatment Plan
- Surgical Pre-Certification Request Form
- Driver questionnaire
- Affidavit of vehicle fire
- Affidavit of vehicle theft
- Notice and proof of claim for disability benefits
- NY motor vehicle no-fault insurance law cover letter
- NY motor vehicle no-fault insurance law application for motor vehicle no-fault benefits
- NY motor vehicle no-fault insurance law election of option – optional basic economic loss coverage
- Report of motor vehicle accident
For questions regarding these forms, please contact your claim representative directly. If you don’t know their name, contact us and we'll connect you to them.
