PIP Application Form NAME OF INSURANCE COMPANYDATE Date Format: MM slash DD slash YYYY OUR POLICY HOLDERDATE OF ACCIDENT Date Format: MM slash DD slash YYYY FILE NUMBERTO 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 NAMEHOME PHONE NUMBERBUSINESS PHONE NUMBERYOUR ADDRESS (NO, STREET, CITY OR TOWN, STATE AND ZIP CODE)PERMANENT ADDRESS, IF DIFFERENTDATE OF BIRTH Date Format: MM slash DD slash YYYY SOCIAL SECURITY NO.HOW LONG HAVE YOU LIVED IN FLORIDA?DATE AND TIME OF ACCIDENT Date Format: MM slash DD slash YYYY PLACE OF ACCIDENT (STREET, CITY OR TOWN AND STATE)BRIEF DESCRIPTION OF ACCIDENT AND VEHICLES INVOLVED:DESCRIBE MOTOR VEHICLE YOU OWNDESCRIBE MOTOR VEHICLE OWNED BY ANY MEMBER OF YOUR FAMILYAS 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 Date Format: MM slash DD slash YYYY DESCRIBE YOUR INJURYWERE YOU TREATED BY A DOCTOR? Yes No DOCTOR'S NAME AND ADDRESSIF YOU WERE TREATED IN A HOSPITAL, WERE YOU AN IN PATIENT OUT PATIENT HOSPITAL'S NAME AND ADDRESSAMOUNT OF MEDICAL BILLS TO DATEWILL 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?YesNoIF YES, AMOUNT OF LOSS TO DATEWHAT IS YOUR AVERAGE WEEKLY WAGE OR SALARY?IF YOU LOST WAGES:DATE DISABILITY FROM WORK BEGANDATE YOU RETURNED TO WORKHAVE YOU RECEIVED, OR ARE YOU ELIGIBLE FOR, PAYMENTS UNDER ANY WORKMEN'S COMPENSATION OR EMPLOYMENT LAW?YESNOIF YES, AMOUNTPER WEEKIF YES, AMOUNTPER MONTHLIST NAMES AND ADDRESSES OF YOUR PRESENT EMPLOYER(S) AND GIVE YOUR OCCUPATION AND DATES OF EMPLOYMENT FOR EACHEMPLOYER AND ADDRESSYOUR OCCUPATIONFROMTO AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES?YESNOIF YES, EXPLAIN ON REVERSE SIDESIGNATURE:DATE Date Format: MM slash DD slash YYYY 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.)SIGNATUREDATE Date Format: MM slash DD slash YYYY 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.SIGNATUREDATE Date Format: MM slash DD slash YYYY
