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What forms do I have to fill out for Personal Injury Protection benefits in an car accident? In Kansas you have PIP benefits available as well as other insurance claims in an auto accident. We will explain the difference in our initial phone conference. In order to determine your eligibility for Personal Injury Protection (PIP) benefits, insurance companies will often send you forms to fill out. We help our clients fill out these forms so be sure to call if you get one of these forms in the mail. It can be tricky filling out the forms but we will help. One of the forms might be an affidavit which must be completed and notarized. By signing the document, you are confirming you are or are not a titled vehicle owner in the State of Kansas. The insurance company will not be able to address any medical bills or lost wages for you until this form is returned. You will need to have a state authorized notary public certify the document prior to sending it back to us. We have a notary in our office so you will come here to sign the affidavit. Once the form is completed, we will mail it back to the PIP insurance carrier for you.

The Affidavit will often look like this: Claim Number:_________________ I, ___________________________ being first duly sworn, depose and state that on __________________, 20 ____ the following is true and correct to the best of my knowledge. (date of accident) 1. My mailing address(es) and place(s) of residence are: __________________________ i. __________________________________________________________ 2. I was not the title owner of the following vehicle: a. Vehicle Make ________________________________________ b. Vehicle Model _______________________________________ c. Vehicle Year _________________________________________ d. Vehicle Identification Number ____________________________ 3. I was not the title owner of any other vehicle located in the state of Kansas on 4. ________________________, 20___. (date of accident) Dated this _____________ day of ___________________, 20 __. Signed by ________________________________________ (Name) The foregoing was subscribed and sworn to before me this _____ day of____________, 20___ STATE OF KANSAS } } SS. COUNTY OF } Witness my hand and official seal. ________________________________ Notary Public My commission expires: _____________________________ Your insurance company will also send you other forms like an authorization to get medical records, a form for you to list the names of your medical providers and then the actual PIP form application itself, all of which we will help you fill out. We will answer all your questions. Call us.