Get Fl C-255fl 2004-2026

Filling out the FL C-255FL is a vital step for individuals seeking to claim medical or wage loss expenses due to injuries from an accident. This guide provides clear and comprehensive instructions for completing the form online.

Follow the steps to complete the FL C-255FL form effectively.

1. Click ‘Get Form’ button to obtain the form and open it in the editing platform.
2. Fill in the current date in the designated section at the top of the form.
3. Input your full name in the provided space, ensuring correct spelling.
4. Enter the date of the accident accurately to reflect when the incident occurred.
5. Include your claim number, which is essential for processing your request.
6. Provide your employer's name in the 'Your Policyholder' section.
7. Complete the 'Occupation' field with your job title to help with claim processing.
8. Indicate your period of employment by filling in the 'From' and 'Through' dates.
9. List the dates you were absent due to the accident, including start and end dates.
10. State whether you were paid during your absence by selecting 'Yes' or 'No,' and if applicable, indicate the amount paid.
11. Answer if you are entitled to benefits under a wage or salary continuation plan.
12. Specify your Workers’ Compensation insurer's name in the given section.
13. Answer whether a claim has been or will be filed under any Workers’ Compensation law for this incident.
14. Fill in the schedule of weekly earnings for a period of 13 weeks prior to the date of the accident, including necessary details for each week.
15. Once all fields are complete, review your entries for accuracy before finalizing.
16. Save your changes and choose to download, print, or share the completed form as needed.

Complete your FL C-255FL form online today for a smoother claims process.