Free JD-VS-8PI - Connecticut

Personal injury comPensation application
JD-VS-8pi Rev. 1/09

section one - Victim information

name of victim (last, first, middle) address city primary language of victim Would you like to be contacted via email? m Yes m no State Zip

Home telephone cell telephone Birth date

Work telephone age Sex

Email

section two - claimant information (Complete if different from victim)

name of claimant (last, first, middle) address city primary language of claimant Would you like to be contacted via email? m Yes m no claimant relationship to victim: m child m brother m spouse m sister m parent m grandchild State Zip

Home telephone cell telephone Birth date

Work telephone age Sex

Email

m grandparent m step child

m spouse's parent m adopted child

m stepparent m administrator

m half brother

m half sister

m party to a civil union

m other (ie. DcF case worker)

For oFFice use only

claim number

claims examiner

section three - contact Person (Person to contact if victim/claimant cannot be reached)

name of contact person (last, first, middle) address Home telephone Work telephone

Relationship to claimant city cell telephone State Zip

section four - attorney rePresentation (Complete only if represented by an attorney for this application)

name of attorney (last, first, middle) address Work telephone Fax

name of firm city Juris number State Zip

section fiVe - crime information (Please fill out this section as completely as possible)
type of crime: m assault Briefly describe the crime: m sexual assault m robbery with injury m dui m hit and run m other

Date of crime Date crime was reported to police police department incident number

address where crime occurred police department to which crime was reported name(s) of assisting officer(s)

Was the crime reported to the police within five days? m yes m no (if not, please explain)

Has an arrest(s) been made? m yes m no m unknown name of offender(s), if known Has the offender(s) been arraigned in court? m yes m no m unknown if yes, court location Docket number

section fiVe a - crime information (Continued)
if victim of sexual assault, was the sexual assault medical examination and evidence collection completed within 72 hours of the assault? m yes m no

if yes, name of hospital/healthcare facility

Date of examination

section six - medical/counseling information

are you applying for compensation of unreimbursed medical, dental and/or mental health counseling expenses? m yes m no if yes, please briefly describe the physical or emotional injuries that resulted from the crime:

list all providers that gave treatment, include hospital, doctors, dentists, mental health counselors, ambulance, radiology and prescriptions (drugs and eyeglasses). attach additional sheets if necessary. if available, please enclose copies of bills. provider's name address telephone

Will there be additional treatment? m yes m no m unknown if yes, provider's name

section seVen - emPloyment information
Were you employed at the time of the crime? m yes m no if yes, are you applying for wage loss compensation? m yes m no

if yes, complete the following section (if self-employed, see SEction SEVEn a).

name of employer

telephone

address

Hours worked per week
$ $

city

State

Zip From

Wage per hour to

tips, bonuses per week total hours absent

Dates absent from work due to crime related injuries

if you have missed more than one week of work, please provide a doctor's statement verifying length of time you were unable to work. name of doctor telephone

address

city

State

Zip

in order for oVS to consider any salary loss, please check any source listed below from which you received financial support. sick leave vacation union/fraternal insurance disability benefits m yes m no m yes m no m yes m no m yes m no Workers compensation unemployment compensation Social Security disability state Medicaid/city public assistance m yes m no m yes m no m yes m no m yes m no other (please list)

section seVen a - self-emPloyment information
if you were self-employed at the time of the crime, please submit a copy of your tax return and documentation (W-2 form, 1099 form, etc.) for the year before the crime. if you have missed more than one week of work, please provide a doctor's statement verifying length of time you were unable to work.

name of doctor

telephone

address

city

State

Zip

in order for oVS to consider any salary loss, please check any source listed below from which you received financial support. Workers compensation unemployment compensation union/fraternal insurance m yes m no m yes m no m yes m no disability benefits Social Security disability state Medicaid/city public assistance m yes m no m yes m no m yes m no other (please list)

section eight - insurance & other collateral source information

Have bills been paid or will bills be paid by any of the following sources? yourself private health insurance Medicare state Medicaid m yes m no m yes m no m yes m no m yes m no Veterans' administration life insurance Workers' compensation other (please list) m yes m no m yes m no m yes m no

name of primary medical insurer

telephone

policy number

address

city

State

Zip

name of secondary medical insurer (if applicable)

telephone

policy number

address

city

State

Zip

please note: if you checked yes to any of the above, medical and mental health counseling bills must be submitted to that source before oVS can consider reimbursement.

section nine - restitution and ciVil action
Did the crime involve motor vehicles? m yes m no (if yes, please provide your automobile insurance policy declarations page.) Did the court order the defendant to make restitution? m yes m no Have you filed or do you intend to file a civil action? m yes m no (if yes, please complete below.)

name of attorney

name of firm

address

city

State

Zip

section ten - statistical information
How did you find out about the crime victims' compensation program? m community advocate m family member m friend/acquaintance m hospital m infoline/211 m medical provider m mental health provider m office of adult probation m oVS victim advocate m oVS webpage m police m poster/brochure m private attorney m prosecutor/state's attorney m public service announcement m telephone book m other

Submission of information regarding race/ethnic background or disabilities is voluntary. m white m black/african american m hispanic m native Hawaiian/pacific islander m unknown

m american indian/alaskan native

m asian

m other

Were you disabled prior to crime? m yes m no

section eleVen - statement of facts and authorization
the undersigned certifies that the information herein is true to his or her best knowledge, information and belief and hereby authorizes any hospital, physician(s) or other person(s) who attended, examined, or rendered services to __________________ (victim's or family member's name), any employer(s) of the victim, any police or other municipal authority or agency, or public authorities including state and federal revenue services, any insurance company or organization having knowledge thereof, to furnish to the oVS or its representative any and all information with respect to the incident leading to the victim's personal injuries and the victim's or family member's application made for compensation. a photocopy of this authorization will be considered as effective and valid as the original.

i,____________________________ , authorize oVS to disclose any information in its possession, including confidential information, to the offices of the court Support Services Division, the State's attorney, the attorney General and to private attorneys retained by oVS or the victim, and to communicate freely with any of the foregoing when such disclosure and communications are necessary pursuant to General Statutes sections 54-208(e), 54-212 and 54-215.

Further, i understand that oVS may be entitled to receive proceeds that an offender has been ordered to pay the victim as restitution ordered by the State of connecticut's criminal court system. this is in accordance with General Statutes section 54-215.

i understand that any recovery of my losses from the offender resulting from a civil action that i have brought entitles oVS to reimbursement of two-thirds of any compensation awarded to me and that oVS shall have a lien on the recovery pursuant to General Statutes section 54-212. i understand that i must notify oVS of the filing of any such civil action within thirty days of the filing of the action in court.

Further, i understand that pursuant to General Statutes section 54-212, oVS shall be subrogated to any cause of action i have against the offender. a civil action may be brought on behalf of oVS by the attorney General or by a private attorney hired by oVS. oVS shall furnish me with a copy of the action within thirty days of the filing of the action in court.

applicant signature (Parent or guardian must sign if victim is a minor or an incompetent adult)

date

Please return completed form to: office of Victim Services 225 Spring Street Wethersfield, ct 06109 contact oVs at: 1-888-286-7347 (toll-free compensation line - ct only) 860-263-2761 www.jud.ct.gov/crimevictim