How to Fill Out a Florida Personal Injury Protection (PIP) Claim Form

To file a Florida PIP claim form, see a qualifying medical provider within fourteen days of the crash, then complete your auto insurer’s Application for Florida No Fault Benefits along with the medical records authorization, the wage information authorization, and (if you lost income) a Wage and Salary Verification form from your employer. Submit the package to your own insurance company, not the other driver’s. Miss the fourteen-day treatment window and the form becomes meaningless: you lose PIP benefits entirely.¹

See a Qualifying Provider Within 14 Days First

Before anything else, get medical care. Florida law requires initial medical services within fourteen days of the accident, with no extensions regardless of how serious the injury turns out to be.¹

Not every provider counts. Your first visit must be with a physician (MD or DO), a dentist, a chiropractor, or an advanced practice registered nurse, or you must be treated at a hospital or hospital-owned facility. Emergency room visits qualify as long as they fall inside the two-week window, and emergency medical transportation providers also count.¹

What that first provider writes down controls your coverage ceiling. A finding that you have an emergency medical condition opens the full $10,000 in benefits. No emergency medical condition means your total PIP coverage drops to $2,500.¹ Hold on to the discharge paperwork from that first visit. It is the foundation of the claim you’re about to file.

Where to Get the Form

The document is titled “Application for Florida No Fault Benefits.” You get it from your own auto insurance carrier, usually through a claims adjuster assigned after you report the accident, or through the company’s online claims portal. The Florida Office of Insurance Regulation publishes a standard version of the form; individual carriers may use their own formatting, but the core sections are the same.²

You file this with your carrier regardless of who caused the crash. PIP is no-fault, so fault investigation isn’t part of this form.

What the Application Asks For

Gather this information before you start. The form groups questions into five areas.

Personal information. Full name, home and business phone numbers, mailing address, permanent address if different, date of birth, Social Security number, and how long you’ve lived in Florida.

Accident details. Date, time, and location of the crash, descriptions of the vehicles involved (yours and any family member’s vehicle), and a brief narrative of what happened.

Injury and treatment. A description of your injuries, the name and address of any treating doctor, whether you were an inpatient or outpatient at a hospital, the hospital’s name and address, total medical bills to date, and whether you expect more.

Employment and wages. Whether you were working at the time of the accident, whether you’ve lost wages, the dollar amount lost so far, your average weekly pay, the date you stopped working, and the date you returned if you have. List your employer’s name and address, your occupation, and your employment dates.

Insurance information. Your auto insurance company, policy number, claim number, adjuster’s name and phone number, and any separate health insurance you carry along with the member ID.²

Read the fraud warning on the form. Knowingly submitting false or misleading information on a PIP claim is a third-degree felony in Florida.² If a figure is uncertain, say so rather than guess.

Sign Both Authorizations on the Back

Two authorization forms are printed on the back of the standard application. Both need your signature or the carrier has grounds to stall your file.

The Authorization for Medical Information lets the insurer request records and billing statements from your doctors, hospitals, and clinics. List every provider you’ve seen since the accident. Omitting one can hold up reimbursement for that provider’s bills.²

The Authorization for Wage and Salary Information lets the insurer contact your employer to verify income. If you’re claiming lost wages, your employer also needs to complete a separate Wage and Salary Verification form, DFS-D0-283, which asks for a schedule of your weekly earnings for the thirteen weeks before the accident.³ Give the form to your payroll or HR contact early. Waiting on a slow employer response is one of the most common reasons wage-loss checks get delayed.

How to Submit the Package

Send the completed application, both signed authorizations, and any supporting documents through your insurer’s online claims portal when possible. Electronic submission creates an instant timestamp. If you mail physical copies, use certified mail with return receipt. That receipt is your proof of delivery if the carrier later says the paperwork never arrived.

Your medical providers have their own filing clock, and you should confirm they’re meeting it. Providers must submit billing statements to the insurer within thirty-five days of rendering treatment. If a provider sends the insurer a notice of initiation of treatment within twenty-one days of first examining you, the billing window extends to seventy-five days.¹ Ask every provider in writing to bill your PIP carrier directly, and follow up. A missed provider deadline usually means that bill comes out of your pocket.

What Happens After You File

Once the insurer has written notice of the covered loss and the amount, a thirty-day clock starts. The carrier must pay, deny, or request more information within that window. Late payments are legally overdue and accrue simple interest.⁴ As of January 2026, that rate is 8.44 percent annually.⁵

If the insurer pays only part of a bill or denies something, the law requires an itemized explanation specifying which charges were reduced or rejected and the information the insurer relied on.⁴ Read every explanation of benefits closely. Carriers routinely reduce charges they consider unreasonable or not medically necessary, and catching an error in the first week is far easier than reversing it later.

Disability payments, once owed, must be issued at least every two weeks rather than held for a single end-of-claim check.¹ Keep an eye on the cadence.

Independent Medical Examinations

The insurer can require you to attend an independent medical examination at any point during your claim. The exam is performed by a doctor the insurer picks and tests whether your continued treatment is medically necessary. Unreasonable refusal to attend lets the insurer cut off all future PIP benefits. Missing two scheduled exams creates a legal presumption that your refusal was unreasonable, shifting the burden to you to explain why.⁴ Treat every exam notice as mandatory.

Why PIP Claims Get Denied

Florida law lets insurers deny benefits outright in a short list of situations:

Injuries you inflicted on yourself intentionally.
Injuries sustained while committing a felony; the carrier can withhold payment while the criminal case is pending, with the thirty-day clock restarting if charges are dropped or you’re acquitted.
Operating the insured vehicle without the owner’s express or implied consent.
Injury to the named insured or a household relative while riding in another vehicle the insured owns but did not insure under the policy.⁴

In day-to-day practice, the denial you’re most likely to run into isn’t on that list. It’s the fourteen-day treatment deadline. Incomplete paperwork, no-shows at independent medical exams, and providers who miss their billing windows round out the common reasons claims fall apart.

Who Can’t Use This Form

Florida’s PIP requirement applies only to motor vehicles with four or more wheels.⁶ Motorcyclists, scooter riders, and their passengers can’t file a PIP claim because the coverage doesn’t exist for those vehicles in Florida. Recovery runs through health insurance, optional medical payments coverage on a motorcycle policy, or a liability claim against the at-fault driver.

PIP does reach beyond just the person driving the covered car. The named insured, household relatives, passengers in the insured vehicle, and pedestrians struck by it all qualify for benefits as long as no exclusion applies.¹ If you were a passenger or a pedestrian and the car’s owner carries PIP, you file on that policy.

1
Justia Law. Florida Code 627.736 – Required Personal Injury Protection Benefits; Exclusions; Priority; Claims
2
Florida Office of Insurance Regulation. Application for Florida No Fault Benefits
3
Florida Department of Financial Services. DFS-D0-283 Wage and Salary Verification
4
Florida Senate. Florida Code 627.736 – Required Personal Injury Protection Benefits; Exclusions; Priority; Claims
5
Florida Department of Financial Services. Judgment Interest Rates
6
The Florida Bar. Consumer Pamphlet: Automobile Insurance