Geico Pip Application Form Details

Geico is one of the most well-known and popular car insurance companies in the United States. If you are looking for a great deal on car insurance, then Geico is definitely worth checking out. In addition to traditional car insurance, Geico also offers speciality policies such as motorcycle and RV coverage. One of the best ways to find out if Geico is right for you is to fill out their form application. This article will tell you everything you need to know about the Geico form application process.

We've gathered some general information about the geico form application. It's really worth spending some time to read through this before starting filling in your document.

QuestionAnswer
Form NameGeico Form Application
Form Length4 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min
Other namesgeico claim form, geico forms, geico lost wages form, geico pip form

Form Preview Example

GOVERNMENT EMPLOYEES INSURANCE COMPANIES

APPLICATION FOR BENEFITS - PERSONAL INJURY PROTECTION

DATE

OUR POLICYHOLDER

DATE OF ACCIDENT

CLAIM NO.

TO ENABLE US TO DETERMINE IF YOU ARE ENTITLED TO BENEFITS UNDER THE PERSONAL INJURY

PROTECTION AND/OR NO-FAULT LAW, PLEASE COMPLETE THIS FORM AND RETURN IT PROMPTLY.

CLAIMS DEPARTMENT

ONE GEICO CENTER

MACON, GA 31296

YOUR NAME AND ADDRESS:

PHONE NUMBER: (I I)

(W)

DATE OF BIRTH:

SSN:

DATE, TIME AND PLACE OF ACCIDENT:

DID YOU OWN ANY AUTOMOBILES ON THE DATE OFTHIS ACCIDENT? Q YES • NO IF YES, PLEASE LIST AUTOMOBILES.

DESCRIPTION OF ACCIDENT AND VEHICLES INVOLVED:

AT THE TIME OF THE

ACCIDENT:

WERE YOUTHE DRIVER OF OUR POLICYHOLDER'S CAR?

Q

YES

Q

NO

WERE YOU A PASSENGER IN OURPOLICYHOLDER'S CAR?

[~] YES

Q

NO

WERE YOU A PEDESTRIAN?

Q

YES

Q

NO

WERE YOU THE DRIVER OF A CAR OTHER THAN OUR POLICYHOLDER'S?

YES

Q

NO

ARE YOU A MEMBER OF OUR POLICYI lOLDER'S HOUSEIIOLD? •

YES •

NO IF YES. WHAT IS YOUR RELATIONSHIP?

AS A RESULT OF THIS ACCIDENT, WERE YOU INJURED? • YES

• NO

IF YES, COMPLETETHE REST OF THIS FORM. IF NO,

SIGN MERE AND RETURN THIS FORM TO US.

 

 

 

SIGNATURE:

DATE:

 

 

DESCRIBE YOUR INJURY:

 

 

 

DID A DOCTOR TREAT YOU? • YES • NO DOCTOR'S NAME AND ADDRESS:

IF YOU WERE TREATED IN A HOSPITAL, WERE HOSPITAL'S NAME AND ADDRESS:

YOU AN

IN-PATIENTOUT-PATIENT

HAVE YOU EVER HAD THE SAME OR A SIMILAR CONDITION? • YES • NO IF YES, STATE WHEN AND DESCRIBE:

IS CONDITION SOLELY A RESULT OF THIS ACCIDENT? • YES • NO

AMOUNT OF MEDICAL BILLS TO

WILL YOU HAVE MORE MEDICAL

DATE:

TREATMENT?

 

• YES • NO

DID YOU LOSE WAGES AS A

IF YES. AMOUNT LOST TO DAT

 

RESULT OF YOUR EMJURY?

 

IF NO, EXPLAIN:

WERE YOU IN THE COURSE OF YOUR

EMPLOYMENT?

• YES D NO

WHAT IS YOUR AVERAGE WEEKLY WAGE OR

SALARY?

• YES • NO

DATE DISABILITY FROM WORK BEGAN:

DATE YOU RETURNED TO WORK:

SEE REVERSE SIDE

C-258 MI (01-05) NS

HAVE YOU RECEIVED, OR ARE YOU ELIGIBLE FOR, BENEFITS UNDER

 

 

 

 

 

ANY WORKER'S COMPENSATION LAW?

YES

NO

IF YES, AMOUNT (CHOOSE ONE):

SOCIAL SECURITY DISABILITY BENEFITS?

YES

NO

PER WEEK

MILITARY SERVICE?

YES

NO

PER MONTH

UNEMPLOYMENT BENEFITS?

YES

NO

 

ANY HEALTH INSURANCE PLAN?

YES

NO

 

MEDICARE/MEDICAID?

YES

NO

 

NAME AND ADDRESS OF YOUR PRESENT EMPLOYER WITH YOUR OCCUPATION AND DATES OF EMPLOYMENT:

AS A RESULT OF YOUR INJURY HAVE YOU HAD ANY OTHER EXPENSES (HOUSEHOLD OR ESSENTIAL SERVICES)?

YES • NO IF YES, EXPLAIN:

SIGNATURE

DATE

IMPORTANT - TO BE ELIGIBLE FOR BENEFITS:

1.COMPLETE AND SIGN THIS APPLICATION WITHIN I YEAR OF THE DATE OF ACCIDENT.

2.SIGN THE INCLUDED AUTHORIZATION.

3.RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE RECEIVED TO DATE, WITHIN 1 YEAR OF

TREATMENT DATE.

C-258 MI (01-05) NS

C LAIM N O .

DATE

AUTHORIZATION TO FURNISH MEDICAL INFORMATION

List below the name and addresses of all persons (Doctors, Dentists, Hospitals, Nurses, Funeral Directors, etc.) who rendered, or who are rendering services in connection with injures sustained in this accident and the amount of bills, if known.

NAME AND ADDRESS

AMOUNT OF BILL

To Whom It May Concern:

 

You are hereby authorized to furnish to the

Insurance Company or any of

its representatives (collectively ;'GEICO") any and all medical information which may be requested concerning the physical condition and treatment therefore, diagnosis, prognosis, and any and all records, files, or other documentation concerning the treatment,

prescription, consultation or other advisory visits or events of

, (DOB

, SSN:

) covering the period of

to Present (and up to and including the date of Provider's

compliance with this Authorization) specifically to include, but not be limited to, such condition and treatment as may pertain to the

loss/claim of, 20 , and to allow its representatives or any physician appointed by it to examine your records concerning said condition or treatment. The information covered by this Authorization includes, but is not limited to, reports, records, test results, X-rays, and any other diagnostic testing, whether in your possession or available to you. Copies of this Authorization

shall be considered as valid as the original. This information is being requested for the purpose of evaluating a claim made by me

and/or preparing and conducting a trial on the issues concerning this claim. This Authorization shall be valid for the duration of the

claim. This is not a release of claims for damages. I further understand that I am entitled to a copy of this Authorization and

acknowledge receipt by signing below. I acknowledge that the information disclosed pursuant to this Authorization may be re- disclosed by GEICO pursuant to applicable law and may no longer be protected by the Heath Insurance Portability and Accessibility

Act (HIPAA).

I acknowledge that I have the right to revoke this Authorization. A revocation of this Authorization must be in writing and sent, via regular U.S. mail, postage pre-paid, to the following: One Geico Center Macon. GA 31296

The revocation of this Authorization shall be effective upon receipt and will be prospective only.

I acknowledge that I am aware that the consequences of my not signing this Authorization can include a delay in the processing/resolution of the claim, a potential denial of the claim, or other consequences recognized by applicable state law and/or the

insurance policy at issue.

AUTHORIZING PARTY:

[Signature of Authorizing Party]

[Printed Name of Authorizing Party]

Description of the Authorizing Party's authority to act:

Witness:

Date:

"For your protection Michigan law requires the following to appear on this form: Any person who knowingly and with intent to injure or defraud any insurer files a application or claim containing any false, incomplete, or misleading information shall, upon conviction, be subject to imprisonment for up to one year for a misdemeanor conviction or up to ten years for a felony conviction and payment of

a fine of up to $5,000.00.

C - 256 - MI

GOVERNMENT EMPLOYEES INSURANCE COMPANIES

WAGE AND SALARY VERIFICATION

DATE

OUR POLICYHOLDER

DATE 01- ACCIDENT

CLAIM NUMBER

Employee's Name

Employee's Address

Dear Sir or Madam:

The above named person sustained injuries as a result of an automobile accident on the date indicated. We understand this person is your employee or former employee. To determine what monies may be due to the injured party, please provide us with responses to

the following questions, and return this form promptly. Thank you for your cooperation.

GOVERNMENT EMPLOYEES INSURANCE COMPANIES

CLAIMS DEPARTMENT

ONE GEICO CENTER

 

MACON, GA 31296

 

 

1.

Occupation:

 

 

 

 

2.

Date of Employment:

From:

 

 

Through:

3.

Dates absent following accident:

From:

 

 

Through:

4.

Was employee paid during this absence?

Yes

No_

If Yes, Amount Paid S

5.

Is employee entitled to benefits under a wage or salary continuation plan?

Yes

No_

 

 

6. Name of your Workers' Compensation Insurer:

 

 

 

 

7.

Has or will a claim be filed under any Workers' Compensation Law for this accident?

Yes

No_

8.

SCHEDULE OF WEEKLY EARNINGS

FOR 13 WEEKS PRIOR TO DATE OF ACCIDENT

WEEK

 

AMOUNT

ADDITIONAL COMPENSATION

 

EARNED

WEEK

 

NO. OF

GROSS

NO.

 

DAYS

INCLUDING

EARNINGS

FROM

TO

WORKED

OVERTIME OR

MEALS BOARD TIPS ALL OTHER

 

 

 

 

 

EXTRA WORK

DATE

DATE

 

 

 

 

 

1

 

 

 

 

2

 

 

 

 

3

4

5

6

7

8

9

10

11

12

13

TOTAL

For your protection, Minnesota law requires the following to appear on this form:

A person who files a claim with intent to defraud or helps commit a fraud against an insurer is guilty of a crime.

EMPLOYER:

DATE:

PHONE #:

TITLE:

SIGNED:

 

PRINT NAME

 

C-255 MN (04-04) NS

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