Ovs Claim Application And Instructions Page 6
ADVERTISEMENT
1
2
3
4
5
6
7If the victim died, tell us about any life insurance and death benefits.
13
(If the victim did not die, or does not have any life insurance or death benefits, skip to 14.)
Company Name
Address
Phone #
Policy or ID #
Life Insurance
(
)
Pension Plan
(
)
Other
Insurance/Plan
(
)
Medicaid
(
)
Workers’
Compensation
(
)
If any other insurance or death benefits, list here:
Do any of these policies cover the victim’s burial expenses?
Yes
No
Has anyone applied for the Social Security Death Benefit?
Yes
No
14 Tell us about your financial
situation. You MUST fill out ALL sections below. If none, enter zero (0).
How many dependents do you have?
What is your total annual income (from ALL sources)? If you are not sure, estimate: $
List ALL your assets and ALL your debts below. If you are not sure, estimate. Attach additional pages, if needed.
Your Assets – If none, enter zero (0).
Your Debts – How much do you owe now?
Savings, stocks, bonds
$
If none, enter zero (0).
Real Property (house, etc.)
$
Mortgage
$
Proceeds from life insurance
$
Loans
$
15 Is a private lawyer (not DA) representing you?
Yes
No
If Yes:
OVS Claim
Civil Suit
Both
(
)
Lawyer’s Name
Address
Phone #
16 Authorization to speak with representative:
If you would like to give permission to a family member, friend or other person to speak to OVS regarding your claim, enter here.
(
)
Name of Person
Address
Phone #
17 Victim/Claimant’s Authorization:
I ACKNOWLEDGE that accepting an award from the Office of Victim Services (OVS) creates a lien in favor of the State of New York on any recovery relating to
the crime upon which this claim is based, including any judgment, settlement or order of restitution. I further authorize any funeral director, attorney, employer,
police or other public authority, insurance company or any person who rendered services to the above, or having knowledge of the same, to furnish the OVS or its
representatives the following information: Workers’ Compensation records, information relating to the crime or any injuries or death suffered as the result of the
crime, and information relating to this claim. If an award is made, I authorize the OVS to make payments directly to the provider of services. I also authorize the
OVS to share my information and records compiled for this claim with the local Victim Assistance Program (VAP) in order for the VAP to assist the OVS in
processing my claim and making its determination. If a private lawyer has been indicated above, I also authorize the OVS to share my information and records
compiled for this claim with the lawyer in order for him/her to act as my representative. I understand a separate Notice of Appearance from my lawyer will be
needed in addition to this authorization. If a family member, friend or other person is indicated above, I authorize the OVS to share my information and records
compiled for this claim with that person in order that they assist me with this claim.
A photocopy of this authorization shall be deemed as effective as the original.
(
)
Claimant’s Signature
Date
Daytime Phone #
Email:
Language you prefer to speak:
_________________________________________
English
Spanish
Simplified Chinese
Traditional Chinese
Haitian Creole
Italian
Korean
Interpreter Needed:
Yes
No
Russian
Other
To process your claim, mail us the following documents. (Keep a copy for your records.)
All bills and receipts for services listed on this form
Your completed, signed claim form
One completed HIPAA form for each service provider listed on this form (You can photocopy the HIPAA form.)
Letters from any insurers denying or authorizing payment for the services listed on this form.
Remember: You must bill your insurance company or benefits plan before the OVS can pay.
New York State Office of Victim Services
Mail your documents to:
AE Smith Building
80 S. Swan Street
Albany, NY 12210-8002
Rev. December 2013
Page 4 of 4
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Financial