Name of Employee____________________________________________ CICF Claim No.______________ Employed from______/______/______ to ______/______/______ Full-time Part-time Seasonal If terminated, when ______/______/______ and why_____________________________________ Average gross WEEKLY wage, including tips and commissions $____________ If hourly, employee worked average of _______ hours per week at a rate of $_________ per hour The number of days worked per week was _____________________ and employee usually worked on: Sunday Monday Tuesday Wednesday Did employee miss work due to crime? Yes Was employee paid for any time missed? Yes No Thursday Friday Saturday If yes, when? ____/____/____ thru ____/____/____ No If no, NUMBER OF DAYS NOT PAID________ If yes, HOW? Please specify what dates were paid and indicate the number of hours/days paid: Vacation leave_____________________________ Sick leave_____________________________ Other____________________________ (please make additional comments on your office letterhead) If insurance benefits are available to the employee through your business (i.e., health, dental, eye care, mental health, life, disability), please provide complete contact information. If more than one carrier, please submit additional information on your office letterhead. Name_____________________________________________________ Policy No._____________________ Address_________________________________________________________________________________ Name of Business___________________________________________ Telephone (____)______________ Signature___________________________________________________ Date_______/_______/_______ Type or Print Name_________________________________________ Title_________________________ THIS FORM MUST BE COMPLETED BY THE EMPLOYER ONLY PLEASE RETURN FORM DIRECTLY TO: Criminal Injuries Compensation Fund (CICF) Post Office Box 26927 Richmond, VA 23261 Rev. 10/06 American LegalNet, Inc. www.FormsWorkFlow.com