Crime Victims Application For Benefits Injury Claim {F800-042-000}

For Office Use Only: Claim No. F800-042-000 Crime Victim222s Application for Benefits 07-2017 Index: APP Crime Victims Compensation Program PO Box 44520 Olympia WA 98504-4520 Crime Victim222s Application for enefits nr ClaimsEmail: CrimeVictimsProgramM@Lni.wa.gov Fax: 360-902-5333Visit our website at www.Lni.wa.gov/CrimeVictims for information Victim nformation Preferred Language (If not English) Email Address Name (First, Middle, Last) Social Security Number (Optional) Telephone Number Date of Birth (mm/dd/yyyy) Sex Male Female Mailing Address City State Zip Code If the victim is a minor, provide the full name of the parent or guardian applying on the victim222s behalf. Name Relationship Who has permission to call CVCP on your behalf? Name Relationship Telephone Number Email Address ter nformation How did you find out about the CVCP? Check the box that applies. Police/Law Enforcement Prosecutor222s Office Victim Assistance Program Advocate Victim Witness Service Hospital Health Care Provider Other: What is your marital status? Check the box that applies. Married Single Domestic Partner Divorced Separated What is your country of origin? What is your ethnicity? Check the box that applies. African American Asian Caucasian Hispanic Native American Pacific Islander Other: Do you have a disability? No Yes Was the disability caused by the crime? No Yes Is the disability: Physical Mental Both What benefits are you applying for? Medical Dental Mental Health Wage Loss American LegalNet, Inc. www.FormsWorkFlow.com For Office Use Only: Claim No. F800-042-000 Crime Victim222s Application for Benefits 07-2017 Index: APP Crime nformation NOTE: The crime must be reported to a police agency Date of Incident (mm/dd/yyyy) Date Reported (mm/dd/yyyy) Time Incident Occurred AM PM Crime Location Address City State Zip Code Did the crime occur on the job? No Yes What law enforcement agency did you report the crime to? Check the box that applies: Police Washington State Patrol Federal Bureau of Investigations Sheriff Tribal Police Officer222s Name Telephone Number Report Number Type of Crime Assault Civil Commitment DUI Failure to Secure Load Sexual Assault Domestic Violence Vehicular Assault Robbery/Burglary Brief Description of the Crime Weapon Used Area of Body Injured Offender222s Name Was the offender living with you when the incident occurred? No Yes If you were involved in a civil commitment proceeding of a sexually violent predator, when were you contacted about the proceedings? Date Who Contacted You Telephone Number Have you filed or do you intent to file a civil suit? No Yes Unsure Attorne nformation Do you have an attorney representing you? No Yes If you have an attorney representing you, check the box that applies: Attorney is representing me for a personal injury claim (auto-insurance) or lawsuit Attorney is representing me for both the crime victim claim and a personal injury claim (auto-insurance) or lawsuit NOTE: If the attorney represents you on your crime victim claim, all department correspondence will go to your attorney. Attorney Name Email Address Telephone Number Address City State Zip Code American LegalNet, Inc. www.FormsWorkFlow.com For Office Use Only: Claim No. F800-042-000 Crime Victim222s Application for Benefits 07-2017 Index: APP ae nformation For wage loss benefits, you must have been employed on the date of the injury or employed in the six months before the injury. Please fill out this section only if you were employed or self-employed at the time of the crime or employed in the six months before the date of the crime and are applying for wage loss benefits. We may contact your employer if necessary. If you have concerns about this, please call us. Were your employed on the date of the crime? No Yes Were you employed in the six months before the crime? No Yes If yes and you are requesting wage replacement benefits, provide the following employer information Employer Name Contact Name Employer Address City State Zip Code Telephone Number Date Last Worked Have You Returned to Work? No Yes If yes, date you returned to work Rate of Pay $ Hour Day Week Month Hours Worked Per Day Days Worker Per Week Additional Earning $ Additional Earning From Piecework Tips Commission Bonuses Did you use sick/vacation leave or disability benefits? No Yes Annual Income Level. Check the box that applies to you $0 $20,000 $20,001 $50,000 $50,001 $75,000 $75,001 $100,000 $100,000 or more nsrance nformation Providing this information ill ensre proper pament of medical epenses Note: You are required to use any available private or public insurance you have first. The Crime Victims Compensation Program is the last payer of benefits. If you have private or public insurance, your provider must bill your insurer first. Please provide accurate information about any insurance you have to ensure bills are paid correctly. Do you have insurance? If yes, provide the information requested below. No Yes The Crime Victims Compensation Program is the payer of last resort. Providers should bill your primary insurance first. Please list all available coverage to include: health insurance, dental insurance, vision insurance, HCA/Medicaid, Veteran, Social Security, DSHS/public assistance, workers222 compensation, Indian Health, automobile insurance (victim and offender), motorcycle insurance, life insurance, home insurance, renter222s insurance. CVCP can only pay benefits after you insurance pays. Attach additional pages if needed. Insurance Company Name Telephone Number Policy Holder Name Provide one of the following: Policyholder ID, Group No., or SSN Date of Eligibility Insurance Company Name Telephone Number Policy Holder Name Provide one of the following: Policyholder ID, Group No., or SSN Date of Eligibility American LegalNet, Inc. www.FormsWorkFlow.com For Office Use Only: Claim No. F800-042-000 Crime Victim222s Application for Benefits 07-2017 Index: APP Provider nformation f o have alread seen a medical or other provider or are completing this form in a medical office or hospital please as the medical professional seeing o to complete the section elo Provider Name Provider222s L&I Provider Number Facility Name Telephone Number Address City State Zip Code Date Patient First Treated for Crime Injury Diagnosis Codes Description of Injury Will the patient lose time from work due to their injuries? No Yes Wage Loss Certified From: To: Provider222s Signature Date American LegalNet, Inc. www.FormsWorkFlow.com For Office Use Only: Claim No. F800-042-000 Crime Victim222s Application for Benefits 07-2017 Index: APP Athoriation to elease Confidential nformation NOTE: The victim or legal guardian must sign this form to be valid I hereby authorize any hospital, physician, funeral director, or other person who provided services; any employer of the victim; any law enforcement agency or other government agency, including state and federal services; any and all insurance companies or any other agency having knowledge necessary for this determination of eligibility of this claim for benefits to furnish to the Crime Victims Compensation Program or its representatives any and all information, including but not limited to documents generated by themselves and others, specifically pertaining to this claim. Other information may be required to determine whether conditions are related to the crime. I understand this may include results of HIV and other sexually transmitted disease testing, alcohol, drug, and psychiatric treatment. I understand that if I receive any recovery of my losses through court-imposed restitution or civil lawsuit against the offender, any insurance settlement, or moneys from any government or private agency, I shall reimburse the State of Washington Crime Victims Compensation Program for any compensation paid out under this claim. By signing below, I certify under penalty of perjury under the laws of the State of Washington that the foregoing is true and correct. If the victim is a minor, parent or legal guardian, please sign. If you are the legal guardian, please send the Crime Victims Compensation Program a copy of the guardianship documentation. Print Name