The following information should be completed by each physician in the group applying for coverage:

Individual Application for NJHPIX Membership and Insurance;

Subscribers Agreement (Original and Copy). The original must be returned to NJHPIX. The copy is for the member’s records.

Claim/Suit/Incident Supplement

If your desired retroactive date precedes the desired effective date, please complete the Prior Acts Application

If the physician group is paying the premium please complete Assignment of Unearned Premium

The following information should be completed on behalf of the group:

Only one of each of the following applications should be completed on behalf of the group:

Entity Liability Application for NJHPIX Membership and Insurance

Allied Employee Application for groups that employ any Allied Health Professionals.

Subscribers Agreement (Original and Copy). The original must be returned to NJHPIX. The copy is for the member’s records.

Claim/Suit/Incident Supplement

If your desired retroactive date precedes the desired effective date, click here, complete the Prior Acts Application and return to NJHPIX.

Office Practice Risk Questionnaire

Surplus Contribution Agreement. Make your check payable to NJHPIX, or if you would like to finance the surplus contribution click here Surplus Contribution and Premium Financing Information and Application