Application To Reopen Claim Form - 2015
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1
2APPLICATION TO REOPEN CLAIM
Department of Labor and Industries
Crime Victims Compensation Program
PO Box 44520
DUE TO WORSENING OF CONDITION
VICTIM INFORMATION
Olympia WA 98504-4520
Complete your portion in FULL
Claim number
for prompt action
Important:
Only use this form if your medical condition has worsened, and your claim has been closed for more than 90 days. If time loss benefits
are paid before a decision about reopening is made and your claim is not reopened, you will be required to repay those benefits. Please
write your claim number above. You will receive information about your reopening request within 90 days of the department's receipt of
the application.
1. Name (first, middle, last)
2. Name changed since claim
3. Home phone no.
4. Soc. Sec. No. (for ID only)
closed?
Yes
No
If yes, list previous name
5. Present home address
6. Mailing address (if different than home address)
7. City
State
ZIP
8. City
State
ZIP
8a. I prefer my correspondence go to my Representative
Address
State
ZIP
Name:
9. Date of original injury
10. Employer at time of original injury
11. What are your present physical complaints?
12. Date claim closed
13. Date condition became worse after
claim closure?
14. Full name of provider treating you at time of claim closure
15. What parts of your body are affected?
16. Have you had any new injuries or illnesses since the date of claim closure?
17. Did your condition worsen due to another injury or accident?
Yes
No
If yes, explain.
Yes
No
If yes, explain.
18. Have you received any medical treatment for this condition since claim closure?
Yes
No
If yes, list name and address of treating provider(s).
19. Provider
Phone number
20. Provider
Phone number
Address
Address
City
State
ZIP+4
City
State
ZIP+4
21. Have you applied for or are you receiving any
Are any other Industrial Insurance compensation? (i.e., Longshore harbor workers, Jones Act, Railroad)
of these benefits? (check all that apply)
If checked, explain
Unemployment
Public assistance
Sick leave
Retirement benefits
22. Are you working?
If no,
Retired
Laid off
23. Last date worked
SSI/SSA
Disability insurance
Yes
No
Why?
Unable to work
Quit
Medicare
Worker compensation
24. Present or last employer
Phone number
Address
City
State
ZIP+4
25. Type of business
26. Your job title and duties
27. How long have you worked for this employer?
NOTE: Persons making false statements in obtaining Crime Victims Compensation benefits are subject to civil and
Dept. use only
criminal penalties. I declare that these statements are true to the best of my knowledge and belief. In signing this
form, I permit doctors, hospitals, clinics or others with medical information to release my medical records to the
Department of Labor and Industries and/or the Crime Victims Compensation Program.
Today’s date
Victim’s signature
X
CONTINUE FOR PROVIDER’S INFORMATION
F800-031-000 Application to Reopen Claim 07-2015
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