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How do I fill this out?
To fill out this application, gather your personal information and details about the accident. Ensure you have all necessary documentation available, including police reports. Carefully complete each section, following any specific instructions provided.
How to fill out the Application for Personal Injury Protection Benefits?
1
Gather all necessary personal and accident information.
2
Carefully complete each section of the application form.
3
Attach copies of required documentation such as police reports.
4
Review your application for completeness before submission.
5
Submit your application either online or via fax/mail.
Who needs the Application for Personal Injury Protection Benefits?
1
Individuals seeking benefits after a personal injury car accident.
2
Residents of Michigan who were involved in an auto accident.
3
Drivers without insurance seeking to claim benefits.
4
Passengers injured in a vehicle during an accident.
5
Motorcyclists looking to apply for personal injury protection.
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What are the instructions for submitting this form?
Submit your completed application to the Michigan Automobile Insurance Placement Facility either by mail to PO Box 532318, Livonia, MI 48153-2318 or via fax at 734-744-8552. Additionally, you may contact them by phone at 734-464-8111. Ensure to include all required documentation and submit as soon as possible after the accident.
What are the important dates for this form in 2024 and 2025?
Applications must be submitted no later than one year from the accident date. Keep track of these deadlines to ensure you remain eligible for benefits. At times, additional documentation may be required, so start your application promptly.
What is the purpose of this form?
The purpose of this form is to request personal injury protection benefits through the Michigan Assigned Claims Plan. It allows injured individuals to access needed benefits following an accident. This ensures that those affected can seek the necessary medical and financial support in a timely manner.
Tell me about this form and its components and fields line-by-line.
- 1. Name of Injured Person: Full name including first, middle, last and suffix.
- 2. Date of Birth: The date of birth of the injured person.
- 3. Social Security Number: The injured person's Social Security number.
- 4. Current Address: Current residential address.
- 5. Date of Accident: The date the accident occurred.
- 6. Description of Injuries: Details about the injuries claimed from the accident.
What happens if I fail to submit this form?
Failing to submit this form within the one-year deadline will result in ineligibility for benefits. Ensure that all sections are completed to avoid delays in processing. Incomplete submissions will be returned.
- Ineligibility: Missing the submission deadline means you cannot claim benefits.
- Delay in Benefits: Incomplete forms may lead to significant delays in receiving assistance.
- Additional Documentation Needed: Submitting an incomplete form may require you to gather and resubmit information.
How do I know when to use this form?
- 1. Car Accidents: When injured as a driver or passenger in a car accident.
- 2. Motorcycle Accidents: To claim benefits if you were riding a motorcycle during the accident.
- 3. Pedestrian Accidents: Use this form if you were struck by a vehicle.
- 4. Insurance Claims: For individuals looking to make claims against their automobile insurance.
- 5. Non-Resident Claims: If involved in an accident as a non-resident of Michigan.
Frequently Asked Questions
How do I download the completed application?
Simply fill out the form and click the download button to save it to your device.
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Yes, you can use our editor to make edits before downloading.
Is there a limit on how many times I can edit the PDF?
No, you can edit the PDF as many times as needed.
What formats can I download the file in?
You can download your completed application as a PDF.
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What if I make a mistake on the form?
You can easily correct any mistakes in the editable fields before downloading.
Can I share the PDF once I've completed it?
Yes, you can generate a shareable link to your completed PDF.
What if I need assistance filling out the form?
Refer to the guidance provided within each section of the application.
Will I receive confirmation after submitting the application?
You will need to check with the insurance facility for submission confirmation.
Can I save my progress while filling out the form?
Currently, you may need to complete the form in one go before downloading.
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