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Get Application For Florida No Fault Benefits

A 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. Name: Address: Phone Number: City, State, Zip Code: Date of Birth: Social Security Number: How long have you been a resident of Florida? Time of accident: Date of accident: Location of.

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