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NJ PIP Conditional Assignment of Benefits (CAOB)

Each New Jersey auto insurer has its own conditional assignment of benefits tied to its DOBI-approved Decision Point Review Plan. The patient directs PIP payment to the provider, and the provider, as a condition of the insurer accepting the assignment, agrees to follow the plan's decision point review, precertification and internal appeal rules and to take unresolved disputes to PIP dispute resolution under N.J.A.C. 11:3-5.

Who completes it

The patient, or a parent or legal guardian, signs the assignment. The treating provider signs the conditions for the office and its medical staff and adds the provider's printed name, TIN and address.

Submitting and payment

How to submit it
Use the form from the patient's own insurer and return it to that insurer or its PIP vendor, such as Premier Prizm for GEICO or Medlogix for State Farm, before or with the first treatment plan or bill.
Who pays
Under the assignment the PIP insurer pays the provider directly; if the provider's noncompliance with the plan triggers a co-payment penalty, the provider may not bill the patient for that portion.

Good to know

  • GEICO's version, for losses on or after 10/1/12, also commits the provider to submit complete, legible records supporting diagnosis, causal relationship and care plan, and to sit for an examination under oath on request.
  • The provider may still pursue the patient when benefits are not payable because the patient violated a policy condition or lacked coverage.
  • Without an accepted conditional assignment, the provider cannot take PIP disputes to arbitration directly.
  • GEICO's form states the assignment may require GEICO's written consent and that GEICO may reject, terminate or revoke it.

Get the official form

Download the current version from the source each time; forms change without notice.

Personal Injury Protection Benefits Conditional Assignment of Benefits

Official pagePDF

Fill it with Vero

If your copy of the form is a fillable PDF, upload it once and Vero Documents fills it from the visit note and the chart, ready for you to review and sign. Download, print, or email the finished form, with the patient’s consent.

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How this list is checked

A form is listed only after its name and number were confirmed on the issuing agency’s or insurer’s own website, or in the form itself. Each entry links to that source. The list was last checked in October 2026. Forms and their requirements change without notice, so check the official page for the current version before you complete one.

Vero is not affiliated with, or endorsed by, the agencies and insurers listed here. Read our editorial policy.

Frequently asked questions

Is there one standard New Jersey conditional assignment of benefits form?

No. Each auto insurer uses its own form under its DOBI-approved Decision Point Review Plan. GEICO publishes a one-page form for losses on or after 10/1/12, and State Farm posts a Medical Provider Package with its conditional assignment by date of loss. Use the version from the patient's insurer.

What does a provider agree to in a PIP conditional assignment?

On GEICO's form, the provider agrees to comply with the Decision Point Review Plan and policy terms, initiate precertification and decision point review requests, use the internal appeals process and then PIP dispute resolution, supply complete records, appear for an examination under oath, and hold the patient harmless for any resulting co-payment penalty.