Geico Form Application PDF 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 Length3 pages
Fillable?Yes
Fillable fields43
Avg. time to fill out9 min 25 sec
Other namesgeico form application, geico no fault form, geico pip application form, fillable geico

Form Preview Example

Instructions

The Application for (PIP) Benefits is your formal application for benefits under the Personal Injury Protection and/or No-Fault Law. To complete this form properly, please provide all requested information, sign and date and include any medical bills you have received when you return the application to GEICO.

(Form Below)

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

3535 WEST PIPKIN ROAD LAKELAND, FL 33811

YOUR NAME AND ADDRESS:

 

 

( E-Mail):

 

 

 

 

 

 

PHONE NUMBER: (H)

(W)

DATE OF BIRTH:

SSN:

 

DATE, TIME AND PLACE OF ACCIDENT:

 

 

 

 

 

 

 

DESCRIPTION OF ACCIDENT AND VEHICLES INVOLVED:

 

 

 

 

 

 

 

 

WERE YOU THE DRIVER OF OUR POLICYHOLDER’S CAR?

YES

NO

AT THE TIME OF THE

WERE YOU A PASSENGER IN OUR POLICYHOLDER’S CAR?

YES

NO

ACCIDENT:

WERE YOU A PEDESTRIAN?

 

YES

NO

 

WERE YOU THE DRIVER OF A CAR OTHER THAN OUR

YES

NO

 

POLICYHOLDER’S?

 

 

 

ARE YOU A MEMBER OF OUR POLICYHOLDER’S HOUSEHOLD?

YES

NO IF YES, WHAT IS YOUR RELATIONSHIP?

AS A RESULT OF THIS ACCIDENT, WERE YOU INJURED?

YES

NO

IF YES, COMPLETE THE REST OF THIS FORM. IF NO,

SIGN HERE 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-PATIENT OUT-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

IF NO, EXPLAIN:

 

 

 

 

 

 

 

AMOUNT OF MEDICAL BILLS TO

 

 

WILL YOU HAVE MORE MEDICAL

 

WERE YOU IN THE COURSE OF YOUR

DATE:

 

 

 

EXPENSES?

 

 

 

 

EMPLOYMENT?

 

 

 

 

YES

NO

 

 

 

 

YES

NO

 

 

 

 

 

 

DID YOU LOSE WAGES AS A

 

 

IF YES, AMOUNT LOST TO DATE:

 

WHAT IS YOUR AVERAGE WEEKLY WAGE OR

RESULT OF YOUR INJURY?

 

 

 

 

 

 

 

 

SALARY?

 

YES

NO

 

 

 

 

 

 

 

 

 

 

 

DATE DISABILITY FROM WORK BEGAN:

 

DATE YOU RETURNED TO WORK:

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

 

 

 

 

ANY WORKER’S COMPENSATION LAW?

 

 

 

YES

NO

IF YES, AMOUNT (CHOOSE ONE):

EMPLOYMENT BY U.S GOVERNMENT?

 

 

 

YES

NO

PER WEEK ___________

MILITARY SERVICE?

 

 

 

 

 

 

 

YES

NO

PER MONTH __________

SEE REVERSE SIDE

C-258 FL (08-11)

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?

YES

NO IF YES, EXPLAIN:

SIGNATURE________________________________________ DATE________________________

IMPORTANT - TO BE ELIGIBLE FOR BENEFITS:

1.COMPLETE AND SIGN THIS APPLICATION.

2.SIGN THE INCLUDED AUTHORIZATION.

3.RETURN PROMPTLY WITH ANY MEDICAL BILLS YOU HAVE RECEIVED TO DATE.

FOR YOUR PROTECTION, FLORIDA LAW REQUIRES THE FOLLOWING TO APPEAR ON THIS FORM:

ANY PERSON WHO KNOWINGLY AND WITH INTENT TO INJURE, DEFRAUD, OR DECEIVE ANY INSURER FILES A STATEMENT OF CLAIM OR AN APPLICATION CONTAINING ANY FALSE, INCOMPLETE, OR MISLEADING INFORMATION IS GUILTY OF A FELONY OF THE THIRD DEGREE.

C-258 FL (08-11)

How to Edit Geico Form Application Online for Free

Handful of tasks are simpler than managing documentation through our PDF editor. There isn't much you should do to edit the geico claim form file - only adopt these measures in the next order:

Step 1: Choose the orange "Get Form Now" button on the following page.

Step 2: At this point, you can alter the geico claim form. Our multifunctional toolbar helps you include, remove, adjust, highlight, as well as undertake other sorts of commands to the words and phrases and areas inside the form.

All of the following segments are going to make up the PDF file:

geico no fault application fields to fill in

Please type in the appropriate details in the DATE, DESCRIBEYOURINJURY, DIDADOCTORTREATYOU, YES, NODOCTORSNAMEANDADDRESS, INPATIENT, OUTPATIENT, HOSPITALSNAMEANDADDRESS, YES, NOIFYESSTATEWHENANDDESCRIBE, YES, NOIFNOEXPLAIN, AMOUNTOFMEDICALBILLSTODATE, WILLYOUHAVEMOREMEDICALEXPENSES, and WEREYOUINTHECOURSEOFYOUREMPLOYMENT area.

Filling in geico no fault application part 2

Write the necessary particulars in YESYESYES, NONONO, IFYESAMOUNTCHOOSEONEPERWEEKPERMONTH, SEEREVERSESIDE, and CFL area.

step 3 to finishing geico no fault application

The YES, NOIFYESEXPLAIN, SIGNATUREDATE, and IMPORTANTTOBEELIGIBLEFORBENEFITS field could be used to indicate the rights and responsibilities of each side.

Completing geico no fault application part 4

Step 3: Select the Done button to save the document. At this point it is at your disposal for transfer to your device.

Step 4: You can generate duplicates of the file toprevent different potential concerns. Don't be concerned, we do not display or track your data.

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