PERSONAL INJURY COMPENSATION APPLICATION JD-VS-8PI 5/14 We are here to help. If you have any questions about filling out this application or the Victim Compensation Program, please call us toll-free at 1-888-286-7347. Please know that it is important that you tell us if your contact information changes. If we cannot reach you, your claim may be closed or you may miss important deadlines set by state law. SECTION 1 ­ VICTIM INFORMATION The victim is the person who was physically injured because of the crime. Parents and legal guardians of a minor child (under 18 years old) and legal guardians or conservators of an incapacitated adult must also fill out Section 3. A separate application must be filled out for each victim who was physically injured. Name of victim (last, first, middle) Address Home telephone Primary language spoken Work telephone Birth date City Cell phone Gender: Email Age State Zip Female Male Other SECTION 2 ­ CLAIMANT INFORMATION The claimant is the person who has expenses because of the crime. If the victim and the claimant are the same person, you do not have to fill out this section. Parents and legal guardians of a minor child (under 18 years old) and legal guardians or conservators of an incapacitated adult must also fill out Section 3. Name of claimant (last, first, middle) Address Home telephone Primary language spoken Relationship to victim: child sister spouse parent grandchild grandparent spouse's parent stepparent brother other half-brother half-sister stepchild adopted child party to a civil union Work telephone Birth date City Cell phone Gender: Female Email Male Other Age State Zip FOR OFFICE USE ONLY Claim Number Claims Examiner American LegalNet, Inc. www.FormsWorkFlow.com SECTION 3 ­ PARENT/LEGAL GUARDIAN/CONSERVATOR INFORMATION This section is for parents and legal guardians of children under 18 years old and legal guardians or conservators of an incapacitated adult. If you have your own expenses because of the crime, please fill out another application and list yourself as the claimant. (A copy of the court order naming you as the legal guardians or conservators must be provided.) Name of parent/legal guardian/conservator (last, first, middle) Address Home telephone Primary language spoken Work telephone City Cell phone Gender: Relationship: Natural/adoptive parent Legal guardian Conservator State Zip Email Male Other Female SECTION 4 ­ ATTORNEY REPRESENTATION Please check if an attorney is representing you on this application, a civil lawsuit, or both and provide the attorney's contact information. Representing me on this application Representing me in a civil lawsuit Name of attorney (last, first, middle) Address Work telephone Fax number Name of firm City Juris number State Zip Email address SECTION 5 ­ CONTACT PERSON (person to contact in case we can't reach you) Name of contact person (last, first, middle) Address Home telephone Work telephone City Cell phone How do you know the contact person? State Email Zip SECTION 6 ­ STATISTICAL INFORMATION How did you find out about the Victim Compensation Program? community advocate family member friend/acquaintance hospital Infoline 211 Internet medical provider mental health provider Office of Adult Probation OVS victim services advocate OVS web page police poster/brochure private attorney prosecutor/state's attorney public service announcement telephone book other Statistics are voluntary but needed for federal reporting requirements. american indian/alaskan native native hawaiian/pacific islander Was the victim disabled before the crime? asian other yes no black/african american white hispanic unknown American LegalNet, Inc. www.FormsWorkFlow.com SECTION 7 ­ CRIME INFORMATION If the crime was a sexual assault, please do not fill out this section but answer the questions in Section 7a. This section must be filled out for all other crimes. Type of crime: m assault m robbery with injury m dui m hit and run m other Briefly describe the crime and physical injuries: Date of crime Date crime was reported to police Police department incident number Was the crime reported to the police within 5 days? m yes Address and city where crime happened Police department crime was reported to Name of police officer investigating the crime m no (If no, please explain) Was someone arrested for the crime? m yes m no m unknown Name of person(s) arrested, if known Did the person(s) arrested go to court? m yes m no m unknown If yes, court location Docket number, if known SECTION 7a ­ SEXUAL ASSAULT CRIMES Date of crime Address and city where crime happened m yes m no Did you go to a hospital for a sexual assault medical examination and evidence collection? If yes, name of hospital or healthcare facility Please check which professional you told about the sexual assault: m alcohol and drug counselor m clinical social worker m counselor m emergency medical services provider m employee of Department of Children and Families m marriage and family therapist m mental health professional m nurse (advanced practice, practical, or registered) m physician or physician assistant m police officer Date of examination m psychologist m resident physician or intern at a Connecticut hospital m sexual assault or domestic violence counselor m surgeon Name of the person you told about the assault Address Telephone number Title City Date you told that person State Zip American LegalNet, Inc. www.FormsWorkFlow.com SECTION 8 ­ CRIME EXPENSES Please list all of the hospitals, doctors, dentists, counselors, ambulance services, radiology services, and others who provided treatment or services because of the crime and list the prescriptions (drugs and eyeglasses) you were given because of it (attach additional pages, if needed) and include copies of any crime related bills. Provider Telephone Address City State Zip SECTION 9 ­ EMPLOYMENT INFORMATION Please fill out this section if you were employed or self-employed at the time of the crime and are applying for lost wages. If self-employed, attach a copy of your tax return and W2 or 1099 form for the year of the crime. If you have not filed your taxes before completing this application, forward the information for the year before the crime happened. Please note that we can only consider taxable income. We will contact your employer for dates absent, salary, and benefit information. If you have a concern about this, please call us. If you missed more than 1 week of work, please provide a docto