PIP Application Form

NAME OF INSURANCE COMPANY
DATE
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OUR POLICY HOLDER
DATE OF ACCIDENT
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FILE NUMBER
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 makes a statement of claim containing any false incomplete or misleading information, is guilty of a felony of the third degree.
YOUR NAME
HOME PHONE NUMBER
BUSINESS PHONE NUMBER
YOUR ADDRESS (NO, STREET, CITY OR TOWN, STATE AND ZIP CODE)
PERMANENT ADDRESS, IF DIFFERENT
DATE OF BIRTH
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SOCIAL SECURITY NO.
HOW LONG HAVE YOU LIVED IN FLORIDA?
DATE AND TIME OF ACCIDENT
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PLACE OF ACCIDENT (STREET, CITY OR TOWN AND STATE)
BRIEF DESCRIPTION OF ACCIDENT AND VEHICLES INVOLVED:
DESCRIBE MOTOR VEHICLE YOU OWN
DESCRIBE MOTOR VEHICLE OWNED BY ANY MEMBER OF YOUR FAMILY
AS A RESULT OF THIS ACCIDENT, WERE YOU INJURED?
- IF YOUR ANSWER IS YES, COMPLETE THE REST OF THIS FORM.
- IF NO, SIGN HERE AND RETURN THIS FORM TO US.
SIGNATURE:
Date
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DESCRIBE YOUR INJURY
WERE YOU TREATED BY A DOCTOR?
- Yes
- No
DOCTOR'S NAME AND ADDRESS
IF YOU WERE TREATED IN A HOSPITAL, WERE
- YOU AN IN PATIENT
- OUT PATIENT
HOSPITAL'S NAME AND ADDRESS
AMOUNT OF MEDICAL BILLS TO DATE
WILL YOU HAVE MORE MEDICAL EXPENSE?
AT THE TIME OF YOUR ACCIDENT, WERE YOU IN THE COURSE OF YOUR EMPLOYMENT?
DID YOU LOSE WAGES OR SALARY AS A RESULT OF YOUR INJURY?
- Yes
- No
IF YES, AMOUNT OF LOSS TO DATE
WHAT IS YOUR AVERAGE WEEKLY WAGE OR SALARY?
IF YOU LOST WAGES:
DATE DISABILITY FROM WORK BEGAN
DATE YOU RETURNED TO WORK
HAVE YOU RECEIVED, OR ARE YOU ELIGIBLE FOR, PAYMENTS UNDER ANY WORKMEN'S COMPENSATION OR EMPLOYMENT LAW?
- YES
- NO
IF YES, AMOUNT
PER WEEK
IF YES, AMOUNT
PER MONTH
LIST NAMES AND ADDRESSES OF YOUR PRESENT EMPLOYER(S) AND GIVE YOUR OCCUPATION AND DATES OF EMPLOYMENT FOR EACH
EMPLOYER AND ADDRESS YOUR OCCUPATION FROM TO
AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES?
- YES
- NO
IF YES, EXPLAIN ON REVERSE SIDE
SIGNATURE:
DATE
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IMPORTANT:
1. TO BE ELIGIBLE FOR BENEFITS COMPLETE AND SIGN THIS APPLICATION
2. SIGN AND ATTACH AUTHORIZATION(S)
3. RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE RECEIVED TO DATE
DO NOT DETACH
AUTHORIZATION FOR MEDICAL INFORMATION

THIS AUTHORIZATION OR PHOTOCOPY HEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY WAGES OR SALARY WHILE EMPLOYED BY YOU. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE FLORIDA “NO FAULT” AUTO INSURANCE LAW (CHAPTER 71-252 F.S.)
SIGNATURE
DATE
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DO NOT DETACH
AUTHORIZATION FOR MEDICAL INFORMATION

THIS AUTHORIZATION OR PHOTOCOPY HEREOF, WILL AUTHORIZE YOU TO FURNISH ALL INFORMATION YOU MAY HAVE REGARDING MY CONDITION WHILE UNDER YOUR OBSERVATION OR TREATMENT, INCLUDING THE HISTORY OBTAINED, X-RAY AND PHYSICAL FINDINGS DIAGNOSIS AND PROGNOSIS. YOU ARE AUTHORIZED TO PROVIDE THIS INFORMATION IN ACCORDANCE WITH THE FLORIDA “NO FAULT” AUTO INSURANCE LAW (CHAPTER 71-252 F.S.)
SOCIAL SECURITY NO.
SIGNATURE
DATE
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