Free Untitled-3 - Washington

Crime Victims Compensation Program Department of Labor and Industries PO Box 44520 Olympia WA 98504-4520

REQUEST FOR SURVIVOR COUNSELING BENEFITS
Note: For your convenience, this form may be folded so the address at left will show in a window envelope.

Please return this form to:

CRIME VICTIMS COMPENSATION PROGRAM DEPARTMENT OF LABOR AND INDUSTRIES PO BOX 44520 OLYMPIA WA 98504-4520

fold

The Crime Victims Compensation program provides survivor counseling benefits, after use of available insurance, for family members of a homicide victim. Family members include parents, spouses, children, siblings, grandparents and those members of the same household who have assumed the rights and duties associated with a family. Each family member applying for this benefit must complete the following form. Duplicates of this form may be made for multiple family members. If you have other insurance available, your provider must bill that insurance first. If you have any questions about these benefits, please call Crime Victims Compensation at 1-800-762-3716.

Homicide Victim's Name Date of Homicide

Crime Victim Claim No.

/
Applicant's Name Address City

/
DOB

/
State ZIP Phone No.

/

(
Relationship to deceased victim Do you have medical insurance? Counselor Name Counselor Address Date If yes, name of insurance company Phone No.

)

Yes

No

(

)

/

/

Applicant's Signature

*

*

If the applicant is a minor, the parent or other legal custodyholder of the applicant may sign.

F800-057-909 req for survivor counseling benefits - English

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