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PIP Claim Information Form
Please complete form fully. Confirming your claim benefits can take 14 business days. Once your benefits are confirmed, you will be contacted by a member of our customer service team.
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* Indicates required question
Today's Date
MM
/
DD
/
YYYY
Name (as it appears on your claim)
*
Your answer
Phone Number (XXX-XXX-XXXX)
*
Your answer
Email Address
*
Your answer
Date of Birth (DOB)
*
MM
/
DD
/
YYYY
Is this 1st party or 3rd party coverage? (we do NOT accept 3rd party coverage)
*
1st Party
3rd Party
Auto Insurance Carrier
*
Your answer
Claim Number
*
Your answer
Adjuster Name & Phone Number (XXX-XXX-XXXX)
*
Your answer
Your Mailing Address
*
Your answer
Date of Injury
*
MM
/
DD
/
YYYY
Do you have a prescription? *Email your prescription to insurance@dreamclinic.com ASAP
*
Yes
No
Questions, Comments, or Additional Information?
Your answer
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