State of New Jersey, Department of the Treasury

Firefighter Claim Reimbursement System

This workflow is for the registration of authorized claim representatives. After your submission has been reviewed and approved, authorized claim representatives will be provided access to the claim submission system.

Governmental Entity and Authorized Representative Information

Governmental Entity Name E.g. Red Engine No. 9 Fire Company

NJCFS Vendor ID# The NJCFS Vendor ID Number is 9 digits or "V" followed by 8 digits.

Governmental Entity Category If the Governmental Entity is organized at the Municipal level, please make that selection above. If the Governmental Entity is organized at the County level, please make that selection above. Otherwise, please select Other.

Municipal

County

Other

County Value is not selected

Municipality Clarification goes here. Value is not selected

For other, please explain:

First Name

Last Name

Title

Address

Telephone

Email Address This field is case sensitive.

Is the Governmental Entity covered by the NJ State Health Benefits Program?

Yes

Are you registering to claim reimbursement for a firefighter covered outside of your health plan coverage? Value is not selected

Formula for case statement (hidden)

If the Governmental Entity is not covered by the NJ State Health Benefits Program, does the Entity have an Insurance Provider or Self-Insured?

Insurance Benefits Provider

Self-Insured

Name of Insurance Benefits Provider

Proof of Identity Please upload a letter on County or Municipal letterhead attesting to your authority to submit claims on behalf of this entity.

State of New Jersey, Department of the Treasury

Firefighter Claim Reimbursement System

As an authorized representative of the governmental entity, I attest to the accuracy and legitimacy of the information submitted herein. I acknowledge that knowingly or willfully submitting false information constitutes insurance fraud and will be investigated and prosecuted to the fullest extent of the law.

Acknowledged

Authorized Representative Signature

Date

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Click here to access the application.

ADM-00001-Registration Firefighter Claim Reimbursement

Governmental Entity and Authorized Representative Information

Hidden Response Mapped Fields & Calculations