Application for Florida "NO FAULT" Benefits

Date

File Number

Insurance Company

Policy Number

Date of Accident

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.

Name

Address

Phone Number

City, State, Zip Code

Date of Birth

Social Security Number

How long have you been a resident of Florida?

Date of accident

Time of accident

Location of accident

Description of accident

Make and model of vechicle you were occupying during accident

As a result of this accident, were you injured?

Yes No

If yes, complete the form, If no, Sign below and return to us.

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.

Signature

Date

Description of Injury

Were you treated by a doctor?

Yes No

If yes, name & address

Were you treated at a hospital?

Yes No

If yes, name & address

Amount of medical expenses to date

Will you have more expenses?

Yes No

At the time of accident, were you employed?

Yes No

If yes, did you lose any wages?

Yes No

If yes, amount lost?

Your weekly salar or wage?

Date disability from work began

Date you returned to work

Have you received benefits under Worker's Compensation?

Yes No

If yes, amount and frequency

Name and addresses of employer or previous employer along with occupation and dates of employment.

Name

Address

Date of employment

Add more

As a result of this accident, have you had any other expenses?

Yes No

If yes, explain below with expense amounts

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.

Signature

Date

Your information will be encrypted.