Download Forms


Below you will find links to commonly used forms that may be downloaded, filled out, and mailed to the claim's branch that is handling your claim.
      Syracuse Branch
      123 Air Cargo Road, Suite #2
      Hancock International Airport
      North Syracuse, NY 13212

You will need the Adobe reader for the forms. If you don't already have it, you may download it by clicking link below:




MV-104 (Report of Motor Vehicle Accident)
Required to be filed with DMV by all drivers involved in reportable motor vehicle accidents. If the property damage of any vehicle is $1,000 or more or there were any personal injuries, all the involved drivers must file form MV-104 (Report of Motor Vehicle Accident). File form MV-104 with the DMV no more than 10 days after the accident. The DMV can suspend your driver's license if you fail to report an accident.

MV-104 Download the form


Insureds (Or Drivers) Supplementary Report
This report is to be completed and submitted back to the Company by the named insured and/or insured vehicle driver in all automobile accidents.

Insureds (Or Drivers) Supplementary Report Download the form


NF1 (Application for No Fault Benefits Cover Letter)
Explanation of NF2 (Application for No Fault Benefits) including general policy limits.

NF1 Download the form


NF2 (Application for No Fault Benefits)
Application for No Fault benefits to be completed by all injured parties in an insured vehicle.
This form is also to be used by eligible injured pedestrians/bicyclists.

NF2 Download the form


DB450 (Notice and Proof of Claim for Disability Benefits)
Application for disability benefits to be completed by all eligible injured parties in an insured vehicle. This form is also to be used by eligible injured pedestrians/bicyclists.

DB450 Download the form


Policy Change Request (Broker Take-out Program)
Use this endorsement form to amend policies that have been written as part of the AutoOne Broker Take-out Program. This form should only be used by producers who have been appointed by an AutoOne representative.

BTO PCR Form Download the form


Acknowledgement of Requirement for Photo Inspection
This form should be used by Broker Take-out appointed producers in compliance with Regulation 79. Please submit when Comprehensive and/or Collision coverage is being added to a policy for a vehicle that did not have this coverage previously.

PI Inspection Form Download the form


Agency PTP Fax
The Agency PTP fax form is used to fax PTP directly to the Payment Processing Department when a payment is received past the cancellation date and timely proof of payment is required. The form is pre-addressed to Payment Processing. For quick identification, please be sure to include the check number, policy number and insuredís name on the fax cover sheet.

Agency PTP Fax Download the form


New Jersey Personal Injury Protection Information and Forms

Informational Letters
These will provide specific information concerning how a medical claim under Personal Injury Protection (PIP) coverage will be handled, including specific requirements which you must follow in order to ensure payment for medically necessary treatment, tests, durable medical equipment and prescription drugs that a named insured or eligible injured person may incur as a result of an auto accident.

Accident Dates prior to 10/13/06:
AutoOne Insurance Decision Point Process Informational Letter. This letter applies to all injured parties with an AutoOne policy and accident dates prior to 10/13/06.
Download the AutoOne 2006 form for AutoOne policy holders.

Camden Fire Insurance Association Initial Info Letter. This letter applies to all injured parties with a Camden policy and accident dates prior to 10/13/06.
Download the AutoOne 2006 form for Camden policy holders.

Accident Dates of 10/13/06 and after:
AutoOne Insurance Decision Point Process Informational Letter. This letter applies to all injured parties with an AutoOne policy and accident dates as of 10/13/06 and after.
Download the Prizm 2006 form for AutoOne policy holders.

Camden Fire Insurance Association Initial Info Letter. This letter applies to all injured parties with a Camden policy and accident dates as of 10/13/06 and after.
Download the Prizm 2006 form for Camden policy holders.

Attending Provider Treatment Form
This form is completed by a treating provider and submitted to Concentra for payment consideration

Attending Provider Treatment Form Download the form

New Jersey Department of Banking and Insurance (NJDOBI)
This link will bring you to the official Web site of the NJDOBI. There you will find additional PIP information for Healthcare Providers.

NJ DOI Web site Link to Web site