How to Fill Out and Submit the Massachusetts PIP Application Form

The Massachusetts PIP application form is the document you send to your auto insurance carrier to turn on up to $8,000 in no-fault medical and wage-loss benefits after a crash. Every Massachusetts auto liability policy already includes this coverage, but the insurer will not start paying until the completed form, with supporting documentation, is in its hands. Below is how to fill it out, what to attach, where to send it, and what the carrier has to do once it arrives.

File It Early, Not Just Within Two Years

The statute reimburses only expenses incurred within two years of the accident date.¹ That is the outer wall, not a target. Send the application within days or weeks of the crash. The sooner the carrier has it, the sooner it can pay your providers directly and keep medical bills from landing in collections while treatment is still ongoing.

Gather Everything Before You Open the Form

Missing information is the most common reason an application stalls. Pull these together first:

Accident details: exact date, time, and street address, plus a short description of how the collision happened, which vehicles were involved, and the injuries you noticed right away.
Police report number, if an officer responded.
Every medical provider who has treated you since the crash: name, address, phone, and the dates of each visit. Include the emergency room, urgent care, your primary care doctor, physical therapists, chiropractors, and any specialists.
Employer name, address, and phone, plus the specific dates you missed work. If you are self-employed, pull tax returns or profit-and-loss statements showing your usual earnings.
Your Social Security number, which the authorization section requires.
Your health insurance information, because the carrier needs it to coordinate payment.

Having a doctor’s note that spells out any work restrictions and their duration will save you a round of back-and-forth later.

Working Through the Form

Accident and Injury Description

Describe the mechanics of the collision specifically. “Rear-ended at a red light on Main Street” is useful; “car accident” is not. List every body part affected, including symptoms that felt minor at the time. Adjusters compare what you wrote on the form against what your medical records say, and understating injuries here creates friction later when bills arrive for treatment the application never mentioned.

Medical Providers

List every provider treating the accident injuries, with the dates of service. The carrier matches incoming bills against this list, so a provider you forgot to include can hold up payment on their invoices. If you start seeing a new provider after you file, say a physical therapist a few weeks in, send the carrier a written update so your file reflects it. PIP covers medical, surgical, X-ray, dental, ambulance, hospital, professional nursing, prosthetic devices, and funeral services related to the accident.¹

Wage Loss and Employment

If you missed work because of your injuries, document it precisely. You need your employer’s contact information and the exact dates you were out under a physician’s restrictions. The form includes a salary verification authorization that lets the insurer confirm your historical pay directly with your employer. PIP reimburses amounts actually lost because you could not work and earn the wages you would have earned in your normal employment.¹ If you were not employed when the crash happened, the statute still covers loss of earning capacity and the cost of hiring someone to perform household services you can no longer do yourself.

Vague entries invite trouble. “Missed about two weeks” gives the adjuster a reason to request more documentation or trim your payment. Attach the doctor’s note on work restrictions if you have it.

Signature and Authorizations

Your signature authorizes the insurer to obtain your medical records and verify your employment. Carriers routinely accept electronic signatures through their claims portals, and an electronic signature on the application carries the same legal weight as ink on paper, so submitting digitally does not weaken anything.

How to Submit It

Send the completed application by a method that creates proof of delivery. Certified mail with return receipt gives you a date-stamped record. Most carriers also accept uploads through an online claims portal, which is faster and generates its own confirmation. Keep copies of everything you send and every attachment.

What the Insurer Has to Do After You File

Once the carrier has your application and a licensed physician’s notification of your disability, it has ten days to begin medical payments or send you a written explanation of why it is not paying.² More broadly, PIP benefits are due as losses accrue, once the insurer has reasonable proof of the expense. Any payment that remains unpaid more than thirty days after the carrier receives that proof accrues interest at one and a quarter percent per month.³

Watch your mail and the online portal. Insurers routinely ask for updated medical records, itemized bills, or employer verification letters, and the thirty-day clock does not help you if you let their requests sit.

The Independent Medical Examination

The insurer can require you to attend an Independent Medical Examination, and the request must come within thirty days of the PIP claim. The examining physician has to be licensed in Massachusetts and must practice the same specialty as the doctor currently treating your injury. The insurer pays for the exam.³

Go to the appointment. Refusing or skipping it gives the carrier grounds to cut off benefits entirely. The examiner’s report goes directly to the insurance company and carries real weight. If the examiner concludes the treatment is no longer related to the accident or is not medically necessary, expect the carrier to reduce or deny further payments on that basis.

If the Carrier Denies or Underpays

The statute lets any unpaid party sue the insurer as a party to a contract for the benefits owed, with the possibility of recovering the unpaid amount, statutory interest, and attorney fees.² A letter from an attorney citing the thirty-day interest provision is sometimes enough to move a stalled file before anything is filed in court.

What You Sign For

You are signing the application under the Massachusetts insurance fraud statute. Exaggerated injuries, invented lost wages, or false information can bring up to five years in state prison, or six months to two and a half years in a house of correction, plus fines of $1,000 to $10,000, mandatory restitution, and a fine that can be set at twice the insurer’s damages.⁴ A fraud finding also lets the carrier deny the entire claim retroactively, including legitimate expenses it already paid. Fill the form out accurately, and keep the records that back up every entry.

1
General Court of Massachusetts. Massachusetts General Laws Chapter 90 Section 34A
2
Mass.gov. Massachusetts General Laws c.90 Section 34M – Personal Injury Protection
3
General Court of Massachusetts. Massachusetts General Laws Chapter 90 Section 34M – Personal Injury Protection
4
General Court of Massachusetts. Massachusetts General Laws Chapter 266 Section 111B