Form : Mo 812-1321 - Application For Crime Victims' Compensation Page 3
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4SECTION VII
INSURANCE AND OTHER COLLATERAL SOURCE INFORMATION
Indicate below if any sources are paying or will pay any of above expenses.
Source Type:
Health Insurance/HMO/PPO
Veterans Administration
Armed Services (TRICARE)
Life Insurance
Auto Insurance
Medicare
Medicaid No.______________________________
Workers’ Compensation No.___________________________________
Provide the following information for each source. (If more than one source is paying, provide additional information on separate sheet)
Insurance Name
Policy Number
Street Address
City
State
Zip Code
Name of Policy Holder
Social Security Number of Policy Holder
Effective Date of Policy/Coverage
AUTO INSURANCE INFORMATION - COMPLETE THIS SECTION ONLY FOR MOTOR VEHICLE CLAIM
Does convicted operator have liability insurance coverage on
If Yes, enter name of carrier and policy limits.
auto?
Yes
No
Street Address
City
State
Zip Code
Policy Number
Does the victim have uninsured motorist coverage on auto?
If Yes, enter name of carrier and policy limits.
Yes
No
Street Address
City
State
Zip Code
Policy Number
Has settlement been made with carrier?
If Yes, which one? (Attach copy of settlement)
Yes
No
(Fill out only if victim was employed at the time of the crime
SECTION VIII
WAGE LOSS/LOSS OF SUPPORT
and a loss is being claimed)
Was victim employed
Is victim applying
Is a dependent applying
at time of crime?
Yes
No
for lost wages?
Yes
No
for loss of support?
Yes
No
Victim’s Employer (at time of crime)
Telephone Number
Victim’s Employer Address
City
State
Zip Code
If victim was self-employed, submit copies of signed Federal Income Tax returns from the year of the crime and the year preceding the crime.
Victim’s net (take home) earnings or income at time of crime (including tips and bonuses) if time loss or loss of support benefits are claimed:
$ _________________ per week.
Date left work due to crime: (Month, Day, Year) __________________________________________________________________________________
Date returned to work: (Month, Day, Year)
______________________________________________________________________________________
Days off for which victim received compensation in the form of accrued sick/vacation leave
Was the crime work-related?
Yes
No
If Yes, has the victim applied for Workers’ Compensation or other employment benefits?
Yes
No
If Yes, please describe. ______________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
Are you receiving or have you received accident or disability benefits from your employer as a result of this injury?
Yes
No
If Yes, please describe. ______________________________________________________________________________________________________
_________________________________________________________________________________________________________________________
SECTION IX
OTHER INFORMATION
Is the victim or claimant considering a civil action against the offender or some other third party for damages claimed herein?
Yes
No
If Yes, please provide the name and mailing address of attorney who will handle the civil action: ____________________________________________
_________________________________________________________________________________________________________________________
RESTITUTION
If the court has ordered the offender to make restitution to you (pay you back), complete the following:
Restitution Order Date ___________________________________ Court _____________________________________ Amount $ ______________
Judge_________________________________________________ How Is It To Be Paid? ________________________________________________
MO 812-1321 (2-14)
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