Ovs Claim Application And Instructions Page 5
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If the victim was injured or died because of this crime, fill out below.
Describe the victim’s injuries, briefly:
_________________________________________________________________________________________________________________________
Did the victim receive any medical treatment?
Yes
No (If No, skip to section10.)
Tell us about the health professionals who treated the victim for injuries related to this crime:
Full Name
Complete Address
Phone #
First Hospital
(
)
___________________________________
______________________________________________________________________
______
____________________
Other Hospital
(
)
___________________________________
______________________________________________________________________
______
____________________
First Doctor
(not in hospital)
(
)
___________________________________
______________________________________________________________________
______
____________________
Other Doctor
(
)
___________________________________
______________________________________________________________________
______
____________________
First Dentist
(
)
___________________________________
______________________________________________________________________
______
____________________
Victim’s Counselor
(
)
___________________________________
______________________________________________________________________
______
____________________
10 Tell us about the victim’s dependents or others who depended on the victim for support.
(If none, skip to 11.)
Name
Date of Birth
Relationship to Victim
Social Security #
Dependent
__ __ __
-
__ __
-
__ __ __ __
Address
Are you the legal
guardian?
Yes
No
Name
Date of Birth
Relationship to Victim
Social Security #
Other
__ __ __
-
__ __
-
__ __ __ __
Dependent
Address
Are you the legal
guardian?
Yes
No
Name
Date of Birth
Relationship to Victim
Social Security #
Other
__ __ __
-
__ __
-
__ __ __ __
Dependent
Address
Are you the legal
guardian?
Yes
No
If more than 3 dependents, attach a separate sheet and check here:
11 Did anyone besides the victim receive counseling because of this crime?
(If no, skip to 12.)
Who received counseling?
Relationship to Victim
Insurance company billed for counseling
Policy or ID #
Counselor’s name, address and phone #:
Who else received counseling?
Relationship to Victim
Insurance company billed for counseling
Policy or ID #
Counselor’s name, address and phone #:
If more than 2 people received counseling because of this crime, check here and attach a separate sheet to describe.
12 List any insurance covering the victim or the victim’s dependents.
If no insurance, write “None” below.
If you have applied but are not covered yet, write “Pending” under Policy or ID #.
Name of person(s) covered by this insurance:
Policy or ID #
Primary Insurance Company
Major Medical Insurance Company
Other Insurance (Union, Dental, Vision, etc.)
Medicare
Medicaid
Workers’ Compensation
Auto Insurance
Other insurance
Rev. December 2013
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