Florida Insurance Trust Claim Intake

Member Number

Location

Select a location from the list.

Person Completing the Form

Name

Job Title

Email Address

Phone Number

Indicate Phone Type

If we have questions, is there an alternate contact?

Claim Type

What type of claim

Report Type

Date of Incident

Enter date as MM/DD/YYYY or use the calendar

Time of Incident

Claimant

Name

SSN

Physical Address

Street Line 1

Street Line 2 (Optional)

City

State

ZIP

Mailing Address (if different)

Phone

Indicate Phone Type

Date of Birth

Enter date as MM/DD/YYYY or use the calendar

Incident Information

Description of the incident

Where did the incident happen?

Workers Compensation

Will the employee miss work due to this injury?

Did the employee die due to incident?

Job title of Injured employee

Employment Type

Rate of Pay

Pay Type

Treatment

Did the claimant seek medical treatment?

Witness

Were there witnesses?

Attachments

Drag and drop files here

Maximum file size: 10 MB per file

Allowed file types: PDF, Word (.doc, .docx), Excel (.xls, .xlsx), Images (.jpg, .png, .gif), Text (.txt), ZIP

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