Crime Victims Compensation Application (Page 3 of 4) in pdf

Crime Victims Compensation Application Page 3

Workers Compensation

Unemployment Compensation

Private, Group, or Employers’ Health Plan

Union or other Disability Plan

Other (specify)

List any other sources of payment : ________________________________________________________________

SECTION IV. – FUNERAL & BURIAL INFORMATION & DEATH BENEFITS

(See Instructions for Section IV.)

A. Funeral and Burial

Are funeral and/or burial expenses claimed? ___ Yes ___ No

If so, in what amount? $ ____________

Have these expenses been paid? ___ Yes __ No

Name of person who paid: _________________________

Relationship, if any, between victim and person who paid: ______________________

B. Insurance

If any dependent(s) of the victim have received or may receive accident or life insurance, please list below:

Name of Insurance Company

Name of Beneficiary

Amount Paid or Due

C. Loss of Support

At the time of death, did the deceased victim contribute financial support for any dependants? ___ Yes ___ No

If so, in what amount per month? $__________

Please list minor (18 years or under) dependents and any other dependents of victim:

Name of Dependent

Relationship to Victim

Date of Birth

Name of Legal Guardian

SECTION V. – EMPLOYMENT INFORMATION

(See Instructions for Section V.)

Are lost wages claimed? ___ Yes ___ No

If so, was the victim employed during the six (6) months immediately prior to the crime? ___ Yes ___ No

Please list all employment during the six (6) months prior to the crime:

Name of Employer

Address

Phone No.

Victim's Job Title

Victim's Net Mo. Wages

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Crime Victims Compensation Application Page 3