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Get Application for Florida No Fault Benefits 2001-2024

APPLICATION FOR FLORIDA NO FAULT BENEFITS NAME OF INSURANCE COMPANY DATE OUR POLICY HOLDER DATE OF ACCIDENT FILE NUMBER TO 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. TO BE ELIGIBLE FOR BENEFITS COMPLETE AND SIGN THIS APPLICATION 2. SIGN AND ATTACH AUTHORIZATION S DO NOT DETACH AUTHORIZATION FOR MEDICAL INFORMATION THIS AUTHORIZATION OR P.

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