MISSOURI DEPARTMENT OF LABOR AND INDUSTRIAL RELATIONS DIVISION OF WORKERS' COMPENSATION TORT VICTIMS' COMPENSATION
QUESTIONS AND AFFIDAVIT REGARDING BENEFIT SOURCES AND PAYMENTS AFFIDAVIT FORM A
3315 W. Truman Blvd. P.O. Box 58 Jefferson City, MO 65102-0058 (573) 751-4231
File No: Claimant's Name: (Please type or print your answers. You may use additional sheets if necessary.) I,
(name of undersigned claimant)
, as part of my claim against the Missouri Tort Victims'
Compensation Fund, hereby answer the following questions truly, accurately and completely. 1. For each policy of insurance insuring the tortfeasor, the tortfeasor's liability, or the tortfeasor's vehicle, please state: a. Name of the insurance company issuing the policy; b. Named insured under the policy; c. Coverages and policy limits; and d. Amounts paid to you, or paid on your behalf, under the policy (without reductions for payments made to your attorney, to health care providers, or to lienholders). Attach copies of insurance policies, certificates of insurance, or declarations pages to explain or supplement your answers.
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2. Identify all insurance policies or coverages which afford, or have afforded, or may afford, any coverage for you, or on your behalf, for any personal injury, property damage, loss of income or earning capacity, or medical bills you sustained, or allege to have sustained, or believe you will sustain in the future, as a result of the tort forming the basis of your claim. Such insurance policies or coverages may include, but are by no means limited to: uninsured motorists coverage, underinsured motorists coverage, collision coverage, medical payments ("med pay") coverage, health or medical insurance, health or medical fund, pool or trust, accident and sickness insurance, homeowners insurance, premises liability insurance, long-term disability insurance, short-term disability insurance, and supplemental insurance. For each such policy or coverage, please state: a. Name of the insurance company issuing the policy, or the name of the fund, pool or trust; b. Named insured or member(s); c. Type(s) of coverage(s) and dollar limits on coverage(s); and d. Amounts paid to you, or paid on your behalf (without reductions for payments made to your attorney, to health care providers, or to lienholders). Attach copies of insurance policies, certificates of insurance, declarations pages, trust agreements or similar documents to explain or supplement your answers.
3. If your claim (or a portion of your claim) is for the death of a spouse or other relative, identify all life insurance policies insuring the life of the deceased, and for each such policy, state: a. Name of the insurance company issuing the policy; b. Named beneficiary(ies) under the policy; c. Amount of the policy; and d. Amounts paid under the policy, and to whom. Attach copies of documents to explain or supplement your answers.
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4. State whether you have received, are receiving, will receive, or may be eligible to receive, any monetary benefits as a result (or partial result) of injuries or losses sustained by you as a result of the tort forming the basis of your claim, from any of the following sources: a. Missouri Crime Victims' Compensation Fund, or a similar fund in any other state or jurisdiction; b. Workers' Compensation benefits from any state or jurisdiction; c. Social Security benefits; d. Tortfeasor or the tortfeasor's property; e. Tortfeasor's estate (i.e., decedent's estate); f. Tortfeasor's conservatorship or guardianship estate; g. Tortfeasor's bankruptcy estate or insolvency estate; h. A trust or estate or which the tortfeasor is a beneficiary; i. Any insurance guaranty fund or self-insured guaranty fund, including, but not limited to, the Missouri Property and Casualty Insurance Guaranty Association, the Missouri Private Sector Individual Self-Insurance Guaranty Corporation, or the Missouri Life and Health Insurance Guaranty Association; j. A bankruptcy estate, insolvency estate, or receivership for any insurance company insuring the tortfeasor, the tortfeasor's liability, or the tortfeasor's vehicle; or k. Court-ordered restitution. For each such source, state the amount(s) you have received, are receiving, or will receive, or the amount(s) you believe you may be eligible to receive. Attach copies of documents to explain or supplement your answers.
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5. Have you received, or are you receiving, any funds from any third-party (e.g., the tortfeasor's spouse, the tortfeasor's parent) on account of the tort forming the basis of your claim? Yes No If yes, identify the source and amount of all such funds.
6. Have you received any treatment at a Veterans' Administration medical facility as a result of your injuries? Yes No
7. Has Medicaid or Medicare paid for any of the medical treatment you received as a result of your injuries? Yes No If yes, attach copies of all correspondence you have received regarding such payments.
8. Have you received, are you receiving, are you entitled to receive, have you applied to receive, or do you anticipate receiving any funds compensating you for damages you have sustained or will sustain as a result of the tort forming the basis of your claim, not otherwise identified hereinabove? Yes No If yes, set forth the source, amount and nature of all such payments.
Oath or affirmation. I,
, under oath or affirmation,
state that the foregoing answers, statements and representations are true and correct to my best knowledge and belief, subject to the penalties of making a false affidavit or declaration.
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