Claim Form - Delaware Victims' Compensation Assistance Program Page 2
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1
2
3SECTION 4. LOSS INFORMATION
Check the type of expenses/losses you are seeking for compensation. You must attempt to recover
your losses from any/all other sources(s).
Medical/Dental
Wage/Income Loss
Funeral/Burial
Mental Health Counseling
Crime Scene Cleanup
Mental Health Counseling
Loss of Support for
Moving
Relocation
Temp. Housing
(Secondary Victim)
Victim’s Dependents
Other
Approximate amount of Loss
Please specify if other:
(Must demonstrate a minimum of $25.00 loss.)
$
Name of Secondary Victim’s (last, first, m.i.)
Relationship to Victim
Address
Phone No.
Date of Birth (MM/DD/YY)
/
/
Other Secondary Victim(s)
Relationship to Victim
Address
Phone No.
Date of Birth (MM/DD/YY)
/
/
SECTION 5. MEDICAL INFORMATION
List all Medical/Dental Providers, and/or those who have provided services to the victim and attach any
medical bills you have received.
Name of Provider
Address
Phone
Amount Due
$
Name of Provider
Address
Phone
Amount Due
$
Name of Provider
Address
Phone
Amount Due
$
Name of Provider
Address
Phone
Amount Due
$
SECTION 6. VICTIM’S EMPLOYER
Complete only if filing for income loss
INFORMATION
Name of Employer
Address
City
State
Zip Code
Telephone Number
Fax Number
Was the victim self-employed?
(
)
(
)
Yes
No
Dates absent from work due to crime related injury
Amount of wages lost due to injuries
From:
To:
$
Victim was released back to work on:
By (Name of physician)
Phone Number of Physician
(
)
SECTION 7. SOURCES OF FINANCIAL
Check all that may apply
ASSISTANCE
Did the victim have insurance at the time of the crime?
Does secondary victim have insurance?
Yes
No
Yes
No
Health
Auto
Workers Compensation
Medicaid
Medicare
SSI
Social Security
Disability Benefits
Homeowners/Renters
General
None
Disability
Assistance
Provider Name:
Policy #
2
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