Personal injury compensation application JD-VS-8PI Rev. 1/09 section one - Victim information Name of victim (last, first, middle) Home telephone Work telephone Address Cell telephone Age City State Zip Birth date Sex Primary language of victim Would you like to be contacted via email? m Yes m No Email section two - claimant information (Complete if different from victim) Name of claimant (last, first, middle) Home telephone Work telephone Address Cell telephone Age City State Zip Birth date Sex Primary language of claimant Would you like to be contacted via email? m Yes m No Email Claimant relationship to victim: m child m brother m spouse m sister m party to a civil union For office use only m parent m grandchild m half brother m grandparent m half sister m step child m spouse’s parent m adopted child m stepparent m administrator m other (ie. DCF case worker) Claim Number Claims Examiner American LegalNet, Inc. www.FormsWorkflow.com section three - contact person (Person to contact if victim/claimant cannot be reached) Name of contact person (last, first, middle) Relationship to claimant Address City Home telephone State Zip Work telephone Cell telephone section four - attorney representation (Complete only if represented by an attorney for this application) Name of attorney (last, first, middle) Name of firm Address City Work telephone Fax State Zip Juris number section five - crime information (Please fill out this section as completely as possible) Type of crime: m assault Briefly describe the crime: Date of crime m sexual assault m robbery with injury m dui m hit and run m other Address where crime occurred Date crime was reported to police Police department to which crime was reported Police department incident number Name(s) of assisting officer(s) Was the crime reported to the police within five days? m yes m no (If not, please explain) Has an arrest(s) been made? m yes m no m unknown Name of offender(s), if known Has the offender(s) been arraigned in court? m yes m no m unknown If yes, court location Docket number American LegalNet, Inc. www.FormsWorkflow.com section five A - crime information (Continued) If victim of sexual assault, was the sexual assault medical examination and evidence collection completed within 72 hours of the assault? m yes m no If yes, name of hospital/healthcare facility Date of examination section six - medical/counseling information Are you applying for compensation of unreimbursed medical, dental and/or mental health counseling expenses? m yes m no If yes, please briefly describe the physical or emotional injuries that resulted from the crime: List all providers that gave treatment, include hospital, doctors, dentists, mental health counselors, ambulance, radiology and prescriptions (drugs and eyeglasses). Attach additional sheets if necessary. If available, please enclose copies of bills. Provider’s Name Address Telephone Will there be additional treatment? m yes m no m unknown If yes, provider’s name American LegalNet, Inc. www.FormsWorkflow.com section seven - employment information Were you employed at the time of the crime? m yes m no If yes, are you applying for wage loss compensation? m yes m no If yes, complete the following section (if self-employed, see SECTION SEVEN A). Name of employer Telephone Address Hours worked per week City Wage per hour Tips, bonuses per week $ $ State Zip Dates absent from work due to crime related injuries From To Total hours absent If you have missed more than one week of work, please provide a doctor’s statement verifying length of time you were unable to work. Name of doctor Telephone Address City State Zip In order for OVS to consider any salary loss, please check any source listed below from which you received financial support. sick leave m yes m no Workers Compensation m yes m no unemployment compensation union/fraternal insurance m yes m no Social Security disability disability benefits m yes m no state Medicaid/city public assistance vacation m yes m no other (please list) m yes m no m yes m no m yes m no section seven a - SELF-employment information If you were self-employed at the time of the crime, please submit a copy of your tax return and documentation (W-2 form, 1099 form, etc.) for the year before the crime. If you have missed more than one week of work, please provide a doctor’s statement verifying length of time you were unable to work. Name of doctor Telephone Address City State Zip In order for OVS to consider any salary loss, please check any source listed below from which you received financial support. Workers Compensation m yes m no disability benefits unemployment compensation m yes m no Social Security disability union/fraternal insurance m yes m no state Medicaid/city public assistance m yes m no m yes m no other (please list) m yes m no American LegalNet, Inc. www.FormsWorkflow.com section eight - insurance & other collateral source information Have bills been paid or will bills be paid by any of the following sources? yourself m yes m no Veterans’ Administration private health insurance m yes m no life insurance Medicare m yes m no Workers’ Compensation m yes m no other (please list) state Medicaid m yes m no m yes m no m yes m no Name of primary medical insurer Telephone Policy number Address City State Zip Name of secondary medical insurer (if applicable) Telephone Policy Number Address City State Zip Please note: If you checked yes to any of the above, medical and mental health counseling bills must be submitted to that source before OVS can consider reimbursement. section nine - restitution and civil action Did the crime involve motor vehicles? m yes m no (If yes, please provide your automobile insurance policy declarations page.) Did the court order the defendant to make restitution? m yes m no Have you filed or do you intend to file a civil action? m yes m no (If yes, please complete below.) Name of attorney Name of firm Address City State Zip section ten - statistical information How did you find out about the crime victims’ compensation program? m community advocate m Infoline/211 m OVS victim advocate m prosecutor/state’s attorney m family member m medical provider m OVS webpage m public service announcement m friend/acquaintance m mental health provider m police m telephone book m hospital m Office of Adult Probation m poster/brochure m other m private attorney Submission of information regarding race/ethnic background or disabilities is voluntary. m white m black/African American m american indian/alaskan native m hispanic m asian Were you disabled prior to crime? m yes m no m native Hawaiian/pacific islander m other m unknown American LegalNet, Inc. www.FormsWorkflow.com section eleven - statement of facts and authorization The undersigned certifies that the information herein is true to his or her best knowledge, information and belief and hereby authorizes any hospital, physician(s) or other person(s) who attended, examined, or rendered services to __________________ (victim’s or family member’s name), any employer(s) of the victim, any police or other municipal authority or agency, or public authorities including state and federal revenue services, any insurance company or organization having knowledge thereof, to furnish to the OVS or its representative any and all information with respect to the incident leading to the victim’s personal injuries and the victim’s or family member’s application made for compensation. A photocopy of this authorization will be considered as effective and valid as the original. I,____________________________ , authorize OVS to disclose any information in its possession, including confidential information, to the offices of the Court Support Services Division, the State’s Attorney, the Attorney General and to private attorneys retained by OVS or the victim, and to communicate freely with any of the foregoing when such disclosure and communications are necessary pursuant to General Statutes sections 54-208(e), 54-212 and 54-215. Further, I understand that OVS may be entitled to receive proceeds that an offender has been ordered to pay the victim as restitution ordered by the State of Connecticut’s criminal court system. This is in accordance with General Statutes section 54-215. I understand that any recovery of my losses from the offender resulting from a civil action that I have brought entitles OVS to reimbursement of two-thirds of any compensation awarded to me and that OVS shall have a lien on the recovery pursuant to General Statutes section 54-212. I understand that I must notify OVS of the filing of any such civil action within thirty days of the filing of the action in court. Further, I understand that pursuant to General Statutes section 54-212, OVS shall be subrogated to any cause of action I have against the offender. A civil action may be brought on behalf of OVS by the Attorney General or by a private attorney hired by OVS. OVS shall furnish me with a copy of the action within thirty days of the filing of the action in court. Applicant signature (Parent or guardian must sign if victim is a minor or an incompetent adult) Date Please return completed form to: Office of Victim Services 225 Spring Street Wethersfield, CT 06109 Contact OVS at: 1-888-286-7347 (Toll-free compensation line - CT only) 860-263-2761 www.jud.ct.gov/crimevictim American LegalNet, Inc. www.FormsWorkflow.com