Application for Benefits: Crime Victims Victims: If you were injured as a result of a crime, complete: Applicants: If you are related to a homicide victim, complete: Injury Form #1 Homicide Form #2 What you need to know before applying for benefits: Police report required: The crime must be reported to a police agency within 12 months of the incident – or within 12 months of when it could have reasonably been reported. Signature required: You must sign your completed application, or we will be unable to proceed. “Payer of last resort:” Our program provides benefits only when all other financial sources (such as medical, auto or life insurance) have been exhausted. Limited funding: There are limits on each type of benefit we provide and our program can only pay benefits as long as there are state funds available for this program. See Title 7.68 RCW, Crime Victims Act How to fill out this application: 1. Find our fillable form by going to www.CrimeVictims.Lni.wa.gov, and enter F800-042-000 in the Forms box. 2. Type in your information, save, and print a paper copy. or Print out a blank copy and fill it out clearly with a ball-point pen. 3. Sign your full name in the signature box, in ink. 4. Mail or fax it to us: Fax: 360-902-5333 Mail: Crime Victims, PO Box 44520 Olympia, WA 98504-4520 Questions? Call us toll-free: 1-800-762-3716 Why we will be asking you for personal information on this form: Because benefit calculations are based on: 1. Number of dependents and family status. 2. Whether there is life, auto or medical insurance and 3. Employment status. Tip: Depending on the benefits you seek, and before we award benefits, we may ask you to provide paperwork that legally documents your information. What happens next: We will send you a letter within a few days to let you know we’ve received this application. If we have all of the information we need, you should have a decision from us within 30-60 days. Provider instructions on next page F800-042-000 Crime Victims Application for Benefits 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com Health Care Providers – Thank you for treating this patient . Are you familiar with L&I’s medical aid rules and fee schedules? Are you a registered L&I Provider? If not, check our website for our requirements: www.Lni.wa.gov For Medical Providers We will be asking you for this essential information on the attached form: n Your L&I Provider Number. This is the same number you use when treating injured workers. n ICD codes and a description of the part of the body specifically affected by this crime. n An estimate of how long your patient may be unable to work and a description of current physical restrictions. This will help us decide whether to arrange for wage-replacement benefits. n A medical or mental health treatment plan for this patient. Include needed diagnostic testing or treatment. Indicate whether the patient has previously been treated for the same or similar physical or mental condition. Reminder: State law considers our n Information about the same/similar medication previously program to be the “payer of last resort.” prescribed for this patient to treat the same or similar physical If your patient has primary/secondary or mental condition. insurance, you must bill them first. Funeral Homes and Burial Providers – Thank you for helping this family. We will be asking you for this essential information on the attached form: n A copy of your Statement of Goods and Services indicating the total amount due. Please check our program’s current maximum burial/funeral benefit: www.CrimeVictims.Lni.wa.gov n Your instructions for who our program will be reimbursing for the funeral/burial fees. This could be the “Applicant,” your company, or others who helped pay for your services. Please provide contact information. or If the Applicant would like us to pay you directly, please provide an Assignment of Benefits form signed by the Applicant indicating this. If the Applicant already has paid for the funeral/burial, let us know who we must reimburse. Send us the paid receipt and name and mailing address of the person who paid. Legal Notices: False Information: Any person claiming benefits under this title, who knowingly gives false information required in any claim or application under this title shall be guilty of a Class C felony when such claim or application involves an amount of five hundred dollars ($500) or more. When such claim or application involves an amount less then $500, the person giving such information shall be guilty of a gross misdemeanor. RCW 51.48.020(2) RCW 7.68.125(3) Public or Private Insurance: Benefits payable under this title shall be reduced by the amount of ANY other public or private insurance available, less a share of attorneys’ fees and costs, if any, incurred by the victim in obtaining recovery from the insurer. RCW 7.68.130(1) “Private Insurance” means ANY source of compensation or payment received from an insurance you have paid for or which has paid you on behalf of the person who caused your injuries. RCW 7.68.020(6) “Public Insurance” means ANY source (state or federal) of compensation or payment received. RCW 7.68.020(6) F800-042-000 Crime Victims Application for Benefits 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com RESET WA WA WA WA WA WA Yes No WA American LegalNet, Inc. www.FormsWorkFlow.com RESET WA WA WA WA WA WA Yes No WA American LegalNet, Inc. www.FormsWorkFlow.com