Washington > Workers Comp > Crime Victims Compensation
Application For Benefits F800-042-000 - Washington
| Application For Benefits Form. This is a Washington form and can be used in Crime Victims Compensation Workers Comp . |
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Application for Benefits: Crime Victims Victims: If you were injured as a result of a crime, complete: Applicants: If you are related to a homicide victim, complete: Injury Form #1 Homicide Form #2 Whatyouneedtoknowbeforeapplyingforbenefits: Policereportrequired:The crime must be reported to a police agency within 12 months of the incident or within 12 months of when it could have reasonably been reported. Signaturerequired:You must sign your completed application, or we will be unable to proceed. "Payeroflastresort:"Our program provides benefits only when all other financial sources (such as medical, auto or life insurance) have been exhausted. Limitedfunding:There are limits on each type of benefit we provide and our program can only pay benefits as long as there are state funds available for this program. SeeTitle7.68RCW,CrimeVictimsAct Howtofilloutthisapplication: 1. Find our fillable form by going to www.CrimeVictims.Lni.wa.gov,and enter F800-042-000 in the Forms box. 2. Type in your information, save, and print a paper copy. or Print out a blank copy and fill it out clearly with a ball-point pen. 3. Sign your full name in the signaturebox, in ink. 4. Mail or fax it to us: Fax: 360-902-5333 Mail: Crime Victims, PO Box 44520 Olympia, WA 98504-4520 Questions? Call us toll-free: 1-800-762-3716 Whywewillbeaskingyouforpersonalinformationonthisform: Because benefit calculations are based on: 1. Number of dependents and family status. 2. Whether there is life, auto or medical insurance and 3.Employment status. Tip:Depending on the benefits you seek, and before we award benefits, we may ask you to provide paperwork that legally documents your information. Whathappensnext: We will send you a letter within a few days to let you know we've received this application. If we have all of the information we need, you should have a decision from us within 30-60 days. Providerinstructionsonnextpage F800-042-000 Crime Victims Application for Benefits 12-2010 American LegalNet, Inc. www.FormsWorkFlow.com Health Care Providers Thank you for treating this patient . Are you familiar with L&I's medical aid rules and fee schedules? Are you a registered L&I Provider? If not, check our website for our requirements: www.Lni.wa.gov For Medical Providers Wewillbeaskingyouforthisessentialinformationontheattachedform: n YourL&IProviderNumber.This is the same number you use when treating injured workers. n ICDcodesand a description of the part of the body specifically affected by this crime. n Anestimateofhowlongyourpatientmaybeunabletoworkand a description of current physicalrestrictions. This will help us decide whether to arrange for wage-replacement benefits. n Amedicalormentalhealthtreatmentplanfor this patient. Include needed diagnostictestingor treatment.Indicate whether the patient haspreviouslybeentreatedfor the same or similar physical or mental condition. Reminder: State law considers our n Informationaboutthesame/similarmedicationpreviously program to be the "payer of last resort." prescribedfor this patient to treat the same or similar physical If your patient has primary/secondary or mental condition. insurance, you must bill them first. Funeral Homes and Burial Providers Thank you for helping this family. Wewillbeaskingyouforthisessentialinformationontheattachedform: n AcopyofyourStatementofGoodsandServices indicating the total amount due. Please check our program's current maximum burial/funeral benefit: www.CrimeVictims.Lni.wa.gov n Yourinstructionsforwhoourprogramwillbereimbursingfor the funeral/burial fees. This could be the "Applicant," your company, or others who helped pay for your services. Please provide contact information. If the Applicant would like us to pay you directly, please provide an Assignment of Benefits form signed by the Applicant indicating this. If the Applicant already has paid for the funeral/burial, let us know who we must reimburse. Send us the paid receipt and name and mailing address of the person who paid. or Legal Notices: FalseInformation:Anypersonclaimingbenefitsunderthistitle,whoknowinglygivesfalse informationrequiredinanyclaimorapplicationunderthistitleshallbeguiltyofaClassCfelony whensuchclaimorapplicationinvolvesanamountoffivehundreddollars($500)ormore.When suchclaimorapplicationinvolvesanamountlessthen$500,thepersongivingsuchinformation shallbeguiltyofagrossmisdemeanor.RCW51.48.020(2)RCW7.68.125(3) PublicorPrivateInsurance:BenefitspayableunderthistitleshallbereducedbytheamountofANY otherpublicorprivateinsuranceavailable,lessashareofattorneys'feesandcosts,ifany,incurred bythevictiminobtainingrecoveryfromtheinsurer.RCW7.68.130(1) "PrivateInsurance"meansANYsourceofcompensationorpaymentreceivedfromaninsuranceyou havepaidfororwhichhaspaidyouonbehalfofthepersonwhocausedyourinjuries.RCW7.68.020(6) "PublicInsurance"meansANYsource(stateorfederal)ofcompensationorpaymentreceived.RCW7.68.020(6) American LegalNet, Inc. www.FormsWorkFlow.com F800-042-000 Crime Victims Application for Benefits 12-2010 CRIME VICTIMS APPLICATION FOR BENEFITS: Injury Form Language Preference (check one) 1. Victim's Name (First-Middle-Last) 4. Social Security Number 5. Home phone # 6. Sex Male (check one) RESET English Spanish Russian Korean Chinese Vietnamese Laotian Cambodian Other: Claim # (reserved for CVCP) 2. Birthdate - - 7. Home address City - ( ) - Female 13. Dependent Children: Include unborn, estimate birthdate. Benefits will be based in part on number of legally dependent children. If you don't have custody, complete item 14. Name Relationship Legal custody (check one) ( State ZIP 8. Message phone # ) - Birthdate 9. Family Status Married Separated Y Y Y Y Y N N N N N - - WA 10. Mailing address (if different from home address) City State ZIP (check one) Widowed Single Registered Domestic Partner Divorced WA 12. Name of person making application (if different) 11. Spouse's name Relationship to victim 14. Name of children's legal guardian Address of children's legal guardian City State ZIP Contact's phone # VICTIMINFORMATION VICTIM INFORMATION Mailing address (if different) City State ZIP WA 16. Do you have a disability? (check one) YES NO 17. Who referred you to our program? (check one) Police Victim Witness Other: Prosecutor's Office Hospital 19. Date claimant employed From To 20. Last day worked (check one) WA Caused by crime? YES 15. Contact person's name (if you don't want us to call you at home) NO 18. What kind of benefits are you applying for? (check all that ap
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