COMMONWEALTH OF VIRGINIA CRIMINAL INJURIES COMPENSATION FUND A DIVISION OF VIRGINIA WORKERS' COMPENSATION COMMISSION 11513 Allecingie Parkway Richmond, VA 23235 Telephone: (804) 378-3434 Toll-Free for Claimants Only: 1-800-552-4007 CLAIM FORM BEFORE COMPLETING THIS APPLICATION, PLEASE READ ALL INSTRUCTIONS. You May Qualify For Compensation If: The crime was committed in Virginia or a country where Virginia residents are not eligible or as a result of a terrorist act. The crime was reported to a law enforcement agency within 120 hours (unless good cause can be shown for not doing so). The victim suffered personal physical injury or death as a result of criminal acts. The victim suffered emotional injury as a result of a felony. The victim cooperated with law enforcement agencies and the courts. The victim was not engaged in any illegal activity at the time of the crime. The victim did not provoke, incite or willingly take part in the incident. The claim is filed within one (1) year from the date of the crime, unless good cause can be shown for late filing. [For crimes occurring prior to July 1, 2001, the filing time may be extended for a period not exceeding, under any circumstances, two years after such occurrence.] The claimant paid or is liable to pay the funeral bill of a victim. The claimant is a surviving family member who suffered emotional injury due to the homicide of a parent, spouse, sibling, child or grandchild. The claim has a minimum value of $100. Compensation Cannot Be Awarded For: Pain, suffering or property loss. (Prosthetic devices are not considered property) Injuries resulting from vehicular accidents. (Except victims of drunk drivers) Attorney's fees. Losses covered by insurance, public funds or estates. INSTRUCTIONS 1. Please type or print with ink, and answer all questions on the form. If it does not apply, mark N/A in that space. 2. Attach all bills, receipts, insurance or benefit statements with application and send copies of additional bills and benefit statements for continuing treatment to above address. All submitted bills must be itemized statements of the services rendered. 3. If the victim is a minor or mentally incompetent, the claimant (person filing for victim) must be an adult who is responsible for the victim's welfare. 4. If the claimant/victim is covered by any resources listed under item 4-D of the application, victim must file a claim with same. 5. If the claimant/victim is not covered by insurance and is treated at a hospital, victim must contact the Department of Social Services within 30 days after leaving the hospital to receive help with payment of hospital bill. 6. If filing for mental health counseling for "survivors" only, complete entire application and attach a copy of the appropriate marriage or birth certificate. 7. Submit original Claim Form with all attachments to Criminal Injuries Compensation Fund at the address shown above. Page 1 of 5 Rev. 10/03 American LegalNet, Inc. www.USCourtForms.com PLEASE CHECK THE BENEFITS FOR WHICH YOU ARE APPLYING: Emergency Award (See 3-B) Medical Expenses Lost Wages Funeral Expenses Loss of Support Survivor Counseling Moving Expenses Crime Scene Clean-Up Other (Specify) _____________________________ 1. GENERAL INFORMATION A. Victim's Name _____________________________________________ Social Security No______________________________ _______ Address Street City Telephone No. ( ) _____________ Home ( State )_______________ Zip Code Birth Date ______________________ Work B. Claimant's Name _____________________________________ Social Security No. _____________________________ Relationship to Victim _______________________________________________________________________ _______ Address Street City Telephone No. ( ) _____________ Home ( State )_______________ Zip Code Birth Date ______________________ Work C. Who referred you to Criminal Injuries Compensation Fund? ______________________________________________ 2. SUMMARY OF CRIME If known: A. Name of Attacker(s) __________________________________ Social Security No. ________________________ Name of Attacker(s) __________________________________ Social Security No. ________________________ B. Victim’s Relationship to Attacker(s) ________________________ Incident Report No. _______________________ C. Location of Crime __________________________________________________________________________ Street or Intersection City ___________________________________ County _________________________ State _____________ D. Date of Crime _______________ Time of Crime ______ a.m. (MM/DD/YYYY) p.m. Date Reported _________________________ (MM/DD/YYYY) E. To what law enforcement agency did you report crime? __________________________________________________ F. Has the case gone to trial? Yes No If yes, when? Did you appear? Yes No Result __________________________________________________________________________________ G. Briefly describe the crime Page 2 of 5 Rev. 10/03 American LegalNet, Inc. www.USCourtForms.com H. Did the Court order attacker(s) to pay any of your expenses? Yes No If yes, what expenses were paid and how much? _____________________________________________________________________________________ 3. EMPLOYMENT A. Did victim miss any time from work because of the injuries? Yes No If yes, complete the following: Employer's Name __________________________________ Telephone No. ( ) _________________0 ______ Address Street City State Zip Code B. An emergency award of up to $2,000 may be made if the victim was employed at the time of the crime but is now without income and will suffer hardship without an immediate award. Do you wish to apply for an emergency award? Yes No 4. RESOURCES AND MEDICAL CARE If the victim is not covered by insurance and is treated at a hospital, victim MUST contact the Department of Social Services to receive help with payment of bill. (There is a 30-day filing period after discharge from the hospital to apply for SLH.) A. Was claimant referred to or did claimant apply for any of the following? Yes No Social Security Welfare State-Local Hospitalization (SLH) Medicaid Workers’ Compensation Other B. List names and complete addresses of medical providers (doctors, hospitals, etc.) who treated victim for crime injuries. Attach plain paper with additional providers. NAME 1. __________________________________________ SPECIALTY ____________________________________ _______ Address Street 2 __________________________________________ City State ____________________________________ _______ Address Street 3. __________________________________________ City State Zip Code ____________________________________ _______ Address Street 4. __________________________________________ City State Zip Code ____________________________________ _______ Address Street Page 3 of 5 Zip Code City State Zip Code Rev. 10/03 American LegalNet, Inc. www.USCourtForms.com C. Attach list and/or receipts of any other expenses incurred as a direct result of these injuries; e.g., prescriptions, mileage to medical providers (include breakdown specifying date, name of provider and round-trip mileage), moving expenses. D. Did victim have coverage by any of the following? Yes No Blue Cross/Blue Shield Private Health Plan Employer’s/Union Group Insurance Medicare Homeowner’s/Renter’s Insurance Automobile Insurance Policy number: ______________________________ Complete name: Address: Group number: _______________________________ Please provide a copy of the front and back of your insurance card. 5. DEATH CLAIM A. Date of Death ________________ (Attach copy of signed funeral contract and copy of death certificate) (MM/DD/YYYY) B. Have you received or will you receive payments of more than $10,000 from the victim's estate ($13,500 if you are No If yes, what is the amount received or to be received?___________________ the victim's spouse) Yes C. At the time of death, did victim contribute financial support to any dependents? Yes amount/month $________________ D. Will dependent(s) receive any benefits from the following? Yes No If yes, No Social Security $______________ Workers' Compensation $______________ Auto Insurance $______________ Other ______________ ______________ E. List name, relationship, date of birth and Social Security number of victim's dependents. (List more on plain paper) Name Relationship __________________ __________________ Date of Birth Social Security Number ________________ ________________ ______________ ______________ - - F. Are you filing for survivor counseling for yourself? Yes No Are you filing for survivor counseling on behalf of the victim's dependents? Yes No If yes to either, provide the counselor's complete name and mailing address in Section 4-B. G. Did victim have any burial or life insurance? Yes Name of Company No If yes, complete the following: Address Amount ______________________ _____________________________ ___ H. Amount of burial expenses $ _______________ Beneficiary _________________ Have burial expenses been paid? Yes by whom? _______________________________ Telephone No. ( If yes, ) ___________________0 _______ Address Street Page 4 of 5 No City State Zip Code Rev. 10/03 American LegalNet, Inc. www.USCourtForms.com 6. THE DEPARTMENT OF JUSTICE IS REQUIRED TO COLLECT THE FOLLOWING DATA: Statistical purposes only and completion of this section is optional. Information relates to victim at time of crime. Ethnic Group: Asian or Pacific Islanders Hispanic (Mexican, Puerto Rican, Cuban or other Spanish culture) Multi-racial African-American/Black American Indian or Alaskan Native Caucasian/White Bi-racial National Origin: ____________________________________ (Country of Birth) Sex: Male Handicap: Female Yes No Age in Years ________ Married Single Divorced If yes, please describe the handicap ________________ 7. NOTARIZED STATEMENTS: Signatures must be witnessed by a notary. A. OATH: I swear or affirm that I am the Claimant; I have read and understand the contents of the application and it is true and complete to the best of my knowledge and belief. I understand the claim shall be denied and I shall be subject to prosecution for perjury (a class 5 felony) if any information I submit is false. B. CONSENT: I agree that award(s) may be paid at the discretion of the Fund directly to person(s) or entities to whom payment is owed. C. REPAYMENT: I agree that if I later recover money from any other source as a result of the crime, including, but not limited to, court-ordered restitution, I agree to immediately repay the award(s) to the Fund pursuant to the Virginia Code §19.2368.11:1(F). please initial ____________ D. SUBROGATION: Are you planning to sue the person(s) or place responsible for this injury? Yes No If yes, please provide the name and phone number of your attorney: _________________________________________ _________________________________________ _______________ It is understood that if I recover any settlement or judgment for damages incurred as a result of the crime, I agree to repay the Fund up to the amount of the award(s). please initial E. COLLECTIONS: Pursuant to Virginia Code §19.2-368.15, I understand that the Fund will pursue repayment of the award from the person(s) responsible for the crime. please initial F. CRIMINAL PROSECUTION: I understand according to Virginia Code §19.2-368.10, the Commission may deny, reduce or withdraw any award upon finding that I have not fully cooperated with all law enforcement agencies. please initial G. AUTHORIZATION: I authorize any hospital, physician, funeral director, or other person who attended or examined (print name of victim) _______________________ and any municipal authority, employer or union, insurance company, social service bureau, Social Security office, or any other person, firm, agency or organization to furnish to the Criminal Injuries Compensation Fund, or its representative, any information requested, including tax data and prior police records, needed to complete the claimant's or victim's claim for benefits. A photocopy of this authorization shall be considered as effective and valid as the original. This authorization is for collection of information related only to this claim. I have read, understood and agree to the information in Paragraphs 7 A, B, C, D, E, F and G. ___________________________________ Print Claimant's name _______________________________________________ Claimant's Signature City/County of ____________________________________, Commonwealth/State of_____________________________ Subscribed and sworn before me this______________ day of _______________________________________, ________. Signature of Notary Public____________________________________________________________________________ My commission expires the ________________________ day of _________________________________, __________. Page 5 of 5 Rev. 10/03 American LegalNet, Inc. www.USCourtForms.com