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Application For Compensation Form. This is a Idaho form and can be use in Crime Victim Workers Compensation.
Tags: Application For Compensation, Idaho Workers Compensation, Crime Victim
APPLICATION FOR COMPENSATION
RETURN APPLICATION TO:
CRIME VICTIMS COMPENSATION PROGRAM
INDUSTRIAL COMMISSION
P.O. BOX 83720
BOISE ID 83720-0041
(208) 334-6080 or (800) 950-2110
PLEASE NOTE: YOU MUST COMPLETE ALL OF THE FOLLOWING INFORMATION ON EACH
OF THE FOUR PAGES OF THIS APPLICATION. PLEASE PRINT CLEARLY.
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1. INFORMATION REQUIRED ABOUT THE VICTIM
SEX: MALE_________ FEMALE____________
VICTIM’S NAME: ______________________________________________________ MARITAL STATUS:_________________
VICTIM’S MAILING ADDRESS: ______________________________________________________________________________
CITY/STATE: _______________________________________ ZIP: ____________________ PHONE :(_______)______________
VICTIM’S SOCIAL SECURITY NUMBER:_________________________________ VICTIM’S BIRTH DATE: ___/_____/_____
VICTIM’S DATE OF DEATH: ____/____/______ (if applicable)
DID THE VICTIM MISS AT LEAST A WEEK OF WORK AS A RESULT OF CRIME RELATED INJURIES?
No____ Yes_____IF YES, please complete the following:
VICTIM’S EMPLOYER’S BUSINESS NAME AT THE TIME OF CRIME:____________________________________________
VICTIM’S EMPLOYER’S MAILING ADDRESS :_________________________________________________________________
CITY/STATE:______________________________________ ZIP:_____________________ PHONE: (_______)_______________
CONTACT PERSON__________________________________________ PAY RATE $__________________ PER HOUR
DATES MISSED WORK: FROM_____________________________ TO _____________________________________
DID THE VICTIM RECEIVE TIPS OR GRATUITIES? No______ Yes _________ If yes, please estimate the amount per week
the victim received _____________________________
2. IF THE VICTIM IS DECEASED, PROVIDE THE FOLLOWING INFORMATION (If the victim is not deceased, SKIP
THIS SECTION AND GO TO SECTION NO. 3)
DID THE VICTIM HAVE CHILDREN OR OTHER DEPENDENTS? __________ IF SO PLEASE COMPLETE THE
FOLLOWING:
Name of Child/Dependent
Date of Birth
Relationship to Victim
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
__________________________________________________________________________________________________________
If additional space is needed, please attach separate sheet of paper
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***CONTINUE TO PAGE 2 OF THE APPLICATION ***
rev: 11/08/04
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3.
IF YOU ARE SIGNING THIS APPLICATION FOR A MINOR, INCAPACITATED OR DECEASED VICTIM, THE
FOLLOWING INFORMATION IS REQUIRED ABOUT YOU
YOUR NAME:_____________________________________________________________________________________________
YOUR EMPLOYER’S NAME:______________________________________________________ PHONE (______)____________
YOUR SOCIAL SECURITY NUMBER: ____________________________________ PHONE (________)___________________
YOUR MAILING ADDRESS: _________________________________________________________________________________
CITY/STATE:__________________________________ ZIP: ________________________
YOUR RELATIONSHIP TO VICTIM: ________________________________________________
(IF LEGAL GUARDIAN and /or CONSERVATOR – YOU MUST PROVIDE COPY OF COURT ORDER)
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4. INFORMATION REQUIRED ABOUT THE CRIME
TYPE OF CRIME: ___________________________________________________________________________________________
DATE OF
AM
CRIME :___________________TIME____________PM ( or From _______________________ To _______________________)
LOCATION
(Street
OF CRIME: (Town/City)_____________________________ address where crime occurred)_______________________________
LAW ENFORCEMENT AGENCY CRIME REPORTED TO:_________________________________________________________
DATE CRIME
AM
DISCOVERED:_____________________________ DATE CRIME REPORTED :_________________TIME ______________PM
NAME OF INVESTIGATING OFFICER__________________________________ REPORT NO :___________________________
NAME OF PERSON(S) WHO COMMITTED CRIME :_____________________________________________________________
RELATIONSHIP TO VICTIM AND AGE OF PERSON(S) WHO COMMITTED CRIME :________________________________
(example: friend, acquaintance, uncle, brother, sister, stranger, etc.)
BRIEFLY DESCRIBE INCIDENT (If additional space is needed, please attach separate sheet of paper)
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
NAME OF VICTIM/WITNESS
COORDINATOR:__________________________________________________________________
HOW DID YOU LEARN OF THIS PROGRAM?___________________________________________________________________
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5. STATISTICAL INFORMATION: The following information is used for statistical purposes only. It is needed to comply with
federal regulations.
Race: White _____ Black _____ Native American _____ Hispanic _____ Oriental/Asian _____ Other ____________
Are you a U. S. citizen? Yes _____ No ______
Are you an Idaho resident? Yes____ No_____
Disabilities: Hearing _____ Mobility _____ Visual ______ Mental ______ Multiple _____ Other ______ None ______
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***CONTINUE TO PAGE 3 OF THE APPLICATION***
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6. INFORMATION REQUIRED ABOUT INSURANCE AND OTHER BENEFIT SOURCES
CHECK IF THE VICTIM IS COVERED BY ANY OF THE FOLLOWING BENEFITS:
CAR INSURANCE
MEDICAL INSURANCE
HEALTH & ACCIDENT INSURANCE
WORKERS COMPENSATION
DISABILITY INSURANCE
SOCIAL SECURITY BENEFITS
INDIAN HEALTH SERVICES
MEDICARE : MEDICARE NO. ____________________
MEDICAID : MEDICAID NO.___________________
Effective Date:_____________________
Effective Date:_____________________
OTHER: (explain)________________________________________________________________________________________
NAME & ADDRESS OF INSURANCE COMPANY:_______________________________________________________________
POLICY NO. AND/OR
______________________________________ TELEPHONE NO: _______________________ CLAIM NO. ________________
PLEASE CHECK WHICH TYPE OF COVERAGE YOUR POLICY IS: ٱMedical ٱAuto ٱLife Insurance ٱHome Owners
SECOND INSURANCE POLICY INFORMATION:
NAME & ADDRESS OF INSURANCE COMPANY _______________________________________________________________
POLICY NO. AND/OR
________________________________________ TELEPHONE NO:____________________ CLAIM NO. _______________
PLEASE CHECK WHICH TYPE OF COVERAGE YOUR POLICY IS: ٱMedical ٱAuto ٱLife Insurance ٱHome Owners
ARE YOU BEING REPRESENTED BY A PRIVATE ATTORNEY IN A CIVIL LAWSUIT OR INSURANCE ACTION
RELATING TO THIS INCIDENT ?__________________
ATTORNEY’S NAME ________________________________________________________ PHONE NO (______)_____________
ATTORNEY’S ADDRESS_____________________________________________________________________________________
CITY/STATE__________________________________ ZIP ______________________________
IF YOU HAVE NOT SUED THE PERSON WHO COMMITTED THE CRIME IN A CIVIL ACTION, DO YOU PLAN TO SUE
THAT PERSON? YES ______________ NO ______________
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7. INFORMATION REQUIRED REGARDING MEDICAL, DENTAL, MENTAL HEALTH TREATMENT, ETC.
LIST NAMES OF ALL DOCTORS, DENTISTS, CLINICS, HOSPITAL, COUNSELORS, AMBULANCE, AND ANY OTHERS
WHO HAVE PROVIDED TREATMENT OR SERVICES TO THE VICTIM RELATING TO THE CRIME. (Attach additional
pages if necessary).
COMPLETE NAME OF PROVIDER
COMPLETE MAILING ADDRESS, CITY, STATE ZIP
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
___________________________________________________________________________________________________________
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****CONTINUE TO PAGE 4 OF THIS APPLICATION****
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EACH OF THE FOLLOWING SECTIONS MUST BE AGREED TO AND SIGNED TO RECEIVE COMPENSATION
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8.
INFORMATION RELEASE
I give permission to release to and receive from any hospital, clinic, doctor, insurance company, employer, mental health provider,
treatment center, person, agency or any other entity any needed information to the IDAHO CRIME VICTIMS COMPENSATION
PROGRAM, for _______________________________________________________ (name of victim). I also give permission to the
Program to release copies of any of my medical or mental health records necessary to the prosecuting attorney to secure restitution
from the alleged offender in order to reimburse the fund.
I understand the information will be used to determine compensation benefits, and that only information needed to make a decision
about the application or any claim for compensation benefits or otherwise deemed necessary by the Program to achieve its statutory
mandate will be requested from other entities or released by the Program. With these exceptions, all information provided will be
kept strictly confidential.
I understand this information release is valid until my claim is closed, as provided in Idaho Code § 72-1014, and that I can cancel this
release by writing to the Program at any time, but that such cancellation will result in my claim not being processed further.
I understand a photocopy or facsimile of this signed form is as valid as the original, and that my signature gives permission for the
release of all information specified in this permission form.
Federal law specifically requires that any disclosure or redisclosure of mental health, drug/alcohol or AIDS related information must
be accompanied by the following written statement:
This information has been disclosed to you from records protected by Federal confidentiality rules (42 CRF Part 2). The Federal
rules prohibit you from making any further disclosure of this information unless disclosure is expressly permitted by the written
consent of the person to whom it pertains or as otherwise permitted by 42 CFR Part 2. A general authorization for the release of
medical or other information is NOT sufficient for this purpose. The Federal rules restrict any use of this information to criminally
investigate or prosecute any drug/alcohol abuse patient.
XXX_____________________________________________________________________ DATE ___________________________
Applicant signature (parent or guardian must sign if victim is a minor)
Printed Name of Applicant ________________________________________relationship to victim _________________________
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9.
REPAYMENT AND SUBROGATION AGREEMENT
I understand that Idaho law requires me to contact and repay the Program if I have already received or receive in the future any
payments from the offender, a civil lawsuit, an insurance program, any other government or private agency or any other source
resulting from the criminal offense upon which this application was made. I also acknowledge that the Program has a first lien against
any money payable to me from any of such sources.
I understand and agree to the terms of this Repayment And Subrogation Agreement.
XXX_____________________________________________________________________ DATE ___________________________
Applicant signature (parent or guardian must sign if victim is a minor)
Printed Name of Applicant ________________________________________relationship to victim_________________________
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10.
APPLICATION CERTIFICATION
I certify that the information in this application is true and correct to the best of my knowledge. I understand that I must use all
financial resources available to me including but not limited to, medical/health insurance, workers compensation, disability insurance,
VA benefits, Medicaid/Medicare, Social Security, auto insurance and sick leave prior to the Program paying any benefits. I
understand by signing below I agree to all of the provisions in this Application for Compensation. If the victim is deceased, I certify
that I have authority to file this application on behalf of all surviving dependents, including minor children, entitled to apply for
benefits under the Program, unless a separate application has been filed for that dependent.
XXX_____________________________________________________________________ DATE ___________________________
Applicant signature (parent or guardian must sign if victim is a minor)
Printed Name of Applicant _________________________________________relationship to victim________________________
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