To enable us to determine if you are entitled to benefits under the Florida personal injury protection law, Please complete this form and return it promptly. Any person who knowingly and with intent to injure, defraud, or deceive any insurance company make a statement of claim containing any false, incomplete or misleading information is guilty of a felony of the third degree.
By typing your name below, you are signing this application electronically. You agree your electronic signature is the legal equivalent of your manual signature on this application.
Name and addresses of employer or previous employer along with occupation and dates of employment.