Geico Form Application PDF Details

For individuals seeking compensation for injuries sustained in accidents under the Personal Injury Protection (PIP) and/or No-Fault Law, navigating the application process can feel daunting. The Geico Application for Benefits form emerges as a critical step in securing the necessary financial support for medical expenses, lost wages, and other related costs. This meticulously structured document requires applicants to furnish detailed information about the accident, involving the date, time, and nature of the incident, alongside personal information and a comprehensive description of the injuries incurred. Furthermore, it inquires about the immediate medical attention received, any previous related medical conditions, and the impact of the accident on the applicant's employment. Ensuring the accuracy and completeness of the provided information is pivotal, as Florida law mandates a stern warning against the submission of false, incomplete, or misleading information, categorizing such actions as a felony. Completing this form, along with providing requested documents such as medical bills and signing the included authorization, stands as an essential stride towards availing PIP benefits, underscoring the importance of attentiveness and honesty throughout the application process.

QuestionAnswer
Form NameGeico Form Application
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesgeico form benefits, how to geico form application, geico lost wages form, geico no fault application

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)

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

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geico pip application form fields to fill in

Please type in the appropriate details in the ARE YOU A MEMBER OF OUR, YES, YES, NO IF YES WHAT IS YOUR, SIGN HERE AND RETURN THIS FORM TO, Signature, DATE, DESCRIBE YOUR INJURY, DID A DOCTOR TREAT YOU, YES, NO DOCTORS NAME AND ADDRESS, IF YOU WERE TREATED IN A HOSPITAL, INPATIENT, OUTPATIENT, and HOSPITALS NAME AND ADDRESS area.

Filling in geico pip application form part 2

Write the necessary particulars in DID YOU LOSE WAGES AS A RESULT OF, YES, IF YES AMOUNT LOST TO DATE, WHAT IS YOUR AVERAGE WEEKLY WAGE, DATE DISABILITY FROM WORK BEGAN, DATE YOU RETURNED TO WORK, YES YES YES, NO NO NO, IF YES AMOUNT CHOOSE ONE PER WEEK, SEE REVERSE SIDE, and C FL area.

step 3 to finishing geico pip application form

The NAME AND ADDRESS OF YOUR PRESENT, AS A RESULT OF YOUR INJURY HAVE, YES, NO IF YES EXPLAIN, SIGNATURE DATE, IMPORTANT TO BE ELIGIBLE FOR, COMPLETE AND SIGN THIS, and FOR YOUR PROTECTION FLORIDA LAW field could be used to indicate the rights and responsibilities of each side.

Completing geico pip application form part 4

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