Form 23776 - Application For Benefits From Violent Crimes Compensation Fund Page 2

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INSURANCE

Were the injuries you sustained covered by any of the following?

Worker's Compensation

Medicare

Medicaid

County Trustee

Medical and / or car insurance amount $

Carrier(s)

Health Maintenance Organization carrier:

Coverage

Are you receiving any of the following as a result of the victimization:

$___________________________________________ Per Month

Social Security disability

$___________________________________________ Per Month

Social Security survivors benefit

$_____________________________________________

TOTAL

Life insurance death benefits

Were you the beneficiary ?

Yes

$___________________________________________ Per Week

Worker's compensation benefits

$_____________________________________ Per Week / Month

Employer disability benefits

EMPLOYMENT INFORMATION

Victim's employment name

Telephone number

(

)

Address (number and street, city, state, ZIP code)

RELEASE

I do hereby release the State of Indiana and the Violent Crimes Compensation Division from any and all liability which might be connected with the

processing and payment of this claim. In the event the fund from which the award is paid, if the claim is allowed, is such that it is necessary to prorate

the payment of the claim, I do hereby release and discharge the State of Indiana and the Violent Crimes Compensation Division from any and all

liability beyond the amount actually paid to me from the fund.

SUBROGATIONS

The claimant hereby certifies that no release has been or will be given in settlement or for compromise with any third party who may be liable in damages

to the claimant; and the claimant, in consideration of any payment and/or award by the Violent Crime Compensation Division in accordance with IC 5-2-

6.1-22, here subrogates the State of Indiana to the extent of any such payment and/or award to any right or cause of action occurring to the claimant

against any third person, and agrees to accept any such payment and/or award pursuant to the provisions of the statute. The claimant hereby authorizes

the State of Indiana to sue in his/her name, but at the cost of the State of Indiana, pledging full cooperation in such action, to execute and deliver all papers

and instruments, and do all things necessary to secure such right to a cause of action.

CONSENT TO PAY PROVIDERS

I do hereby consent and agree that if an award is made, money due and owing to any provider of medical services and due to any other qualified person

or entity, including any attorney's fees allowed to my attorney, may be paid direct to said provider, entity or attorney by the agency and need not be paid

to me.

AUTHORIZATION TO RELEASE INFORMATION

I hereby authorize any hospital, physician, or other person, who attended or examined ____________________________________________________

any undertaker or other person who rendered services; any employers of the victim; any police or other municipal authority or agency, or public authority;

any insurance company or organization, or its representative, to release any and all information with respect to the incident resulting in the victim's personal

injury or death, and the claim made herewith for benefits. A photocopy of this authorization will be considered as effective and valid as the original.

I the undersigned Claimant, hereby certify under the penalties of perjury that the statements made herein are true to the best of my knowledge and belief and were made for the

purpose of inducing the State of Indiana to award benefits to me for losses incurred as described above through the Violent Crime Victims Compensation Fund as prescribed in

IC 5-2-6.1-40.

Signature of claimant

Date