Application For Benefits - Personal Injury Protection
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1
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3APPLICATION FOR BENEFITS - PERSONAL INJURY PROTECTION
KENTUCKY NO-FAULT
IM PORTANT:
1.
To enable us to determ ine if you are entitled to benefits under the policyholder’s
contract, you m ust com plete and sign this form .
2.
You must also sign the attached authorization(s).
3.
Return prom ptly w ith any m edical bills you have received to date. How ever, you should
not w ait for your m edical bills to arrive before sending this application to us. Please
send this application back im m ediately.
DATE
OUR POLICYHOLDER
DATE OF ACCIDENT
FILE NO .
Any person who know ingly and with intent to defraud any insurance com pany
_____________________
or other person files a statem ent of claim containing any m aterially false
Claim Dept.
inform ation or conceals, for the purpose of m isleading, inform ation concerning
any fact m aterial thereto com m its a fraudulent insurance act, w hich is a crim e.
YO UR NAME
HO ME PHO NE NUMBER
W O RK PHO NE NUMBER
YO UR ADDRESS (NO ., STREET, CITY OR TO W N, STATE AND ZIP CO DE)
DATE O F BIRTH
SOCIAL SECUR ITY NUMBER
DATE AND TIME OF ACCIDENT:
BRIEF DESCRIPTIO N O F ACCIDENT:
DO YOU OR ANY MEMBER OF YOUR HO USEHO LD
O W N A MO TO R VEHICLE?
YES
NO
PLEASE LIST ALL AUTO INSURANCE CARRIERS CURRENTLY CO VERING ANY O R ALL O F THE VEHICLES YO U O W N NAME O F
INSURANCE CO MPANY AND PO LICY # :
W ERE YO U THE DRIVER O F THE MO TO R VEHICLE?
YES
NO
W ERE YO U A PASSENG ER IN THE MO TO R VEHICLE?
YES
NO
W ERE YO U A PEDESTRIAN ?
YES
NO
W ERE YOU A MEMBER OF THE MO TO R VEHICLE
O W NER’S HO USEHO LD?
YES
NO
HAVE YOU REJECTED NO-FAULT COVERAGE (I.E. PERSONAL INJURY PROTECTION COVERAGE) AS PROVIDED BY THE
KENTUCKY NO -FAULT ACT (KAS304.39) BY SIG NING A REJECTION FO R THIS CO VERAG E?
YES
NO
W ERE YOU INJURED AS A RESULT OF THIS ACCIDENT
YES
NO
IF YO UR ANSW ER IS YES, CO MPLETE THE REST OF THIS FO RM.
IF NO , SIG N HERE AND RETURN THIS FORM TO US.
SIG NATURE:
_____________________________________________ DATE:_____ _____________
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