Criminal Injuries Compensation Fund Claim Form

Claim Form Before you fill out this application, please read the information below. You may qualify to receive payment if: The victim Before you complete this application: If the victim is a minor or is mentally incompetent suffered physical injury or was killed as a result of a criminal act suffered emotional injury as the result of a felony cooperated with law-enforcement agencies and the courts was not involved in any illegal activity at the time of the crime did not provoke or willingly take part in the incident provide proof you are the adult responsible for the victim's welfare (either parent, guardian or legal custodian) If the victim is covered by any insurance program The crime was committed in Virginia, or a country where Virginia residents are not eligible for compensation was the result of a terrorist act was reported to a law-enforcement agency within 120 hours (5 days), unless there is a good reason for the delay make sure you have first filed a claim with the health insurance provider; Medicare; private health plan; homeowners' or renter's insurance agency; employer's or union group's insurance plan; or automobile insurance company You If the victim was treated at a hospital but not covered by insurance paid or a responsible for paying the victim's funeral bill are a surviving family member who suffered emotional injury due to the murder of a parent, spouse, sibling, child or grandchild This claim make sure to contact the hospital's patient accounting office to apply for charity care assistance. CICF will need to be provided with a copy of the decision made on your charity care application. is being filed within one year from the date of the crime, unless there is a good reason for the delay is filed only after you have exhausted all other financial resources (except income from your salary) How to complete this application: If you need help filling out this application: You cannot be paid for: pain, suffering, or property loss injuries resulting from vehicular accidents (unless the driver was under the influence of alcohol) attorney fees missed doctor's appointments call 1-800-552-4007 (toll-free) e-mail cicfmail@vwc.state.va.us contact your local Victim Witness program Attach all itemized statements for services rendered; receipts; and insurance or benefit statements to this application. * If you receive additional bills and/or benefits statements for continuing treatment, you may mail them to CICF at a later date. Legal considerations: you are required to cooperate with all law-enforcement agencies including prosecuting attorneys while your claim is pending, healthcare providers are prohibited by law from initiating collections action against you Mail this completed application form, along with all attachments, to: Criminal Injuries Compensation Fund P.O. Box 26927 Richmond, Virginia 23261 04/10 American LegalNet, Inc. www.FormsWorkFlow.com 1. Claim Summary Check all desired compensation. Medical expenses payment or reimbursement for crime-related expenses with a hospital, physician, dentist, or other medical provider Moving expenses (up to $1,000) reimbursement for the cost of professional movers, moving equipment rental, temporary storage, first month's rent, and loss of a security deposit Mental health expenses mental health counseling for the victim of the crime Mileage reimbursement of mileage to and from doctors' appointments; mileage to and from court appearances, if the victim is a minor Mental health expenses (up to $2,500) grief counseling for dependents and survivors of homicide victims Funeral or burial expenses (up to $5,000) payment or reimbursement for the victim's burial, cremation and/or headstone and/or plot Prescriptions reimbursement for medication that was prescribed as a result of the crime Loss of wages compensation for the victim who lost wages due to the crime, as verified by a medical provider Home security reimbursement for replacement of doors, locks, windows, and installation of home security system Loss of financial support compensation for dependents of homicide victims, and for victims of domestic violence or child sexual assault when the offender is removed from the home Other reimbursement for replacement of eyeglasses, hearing aids, dentures or other medically necessary aids Crime scene clean-up cleaning of items damaged as a result of the crime ____________________________________________________________________________________________________________ A. If known: What is the status of criminal case?______________________________________________________________ What court was/will the criminal case be heard? Juvenile & Domestic General District Circuit Yes No B. Will there be a civil lawsuit filed against the person or place responsible for the injury? Name of attorney__________________________________________________Phone number of attorney__________________ Address _________________________________________________________________________________________________ C. Who referred you to the Criminal Injuries Compensation Fund? Police/Sheriff's Office Commonwealth's Attorney Office Other Victim Witness Program Attorney's Office Hospital Medical Doctor Name of contact, if known__________________________________________ ------------------------------------------------------------------------------(Optional)-----------------------------------------------------------------------------------Victim's ethnic group African-American/Black American Indian/Alaskan native Married Single Handicapped prior to crime? Asian or Pacific Islander Bi-racial Divorced Age __________ Yes No Caucasian/White Hispanic Male Female How? ___________________________ Page 2 American LegalNet, Inc. www.FormsWorkFlow.com Description of the victim at the time of the crime 2. Claim Information A. Victim's name___________________________________________________________________________________ First Middle Last Social security number_________________________________Date of birth________________________________ Street address________________________________________County____________________________________ City_________________________________________________State________________Zip___________________ Home phone number_____________________________Work phone number______________________________ B. Complete only if you are applying on behalf of the victim Applicant's name________________________________________________________________________________ First Middle