Idaho > Workers Compensation > Crime Victim
Family Assistance Application CV-02 - Idaho
| Family Assistance Application Form. This is a Idaho form and can be used in Crime Victim Workers Compensation . |
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Crime Victims Compensation Idaho Industrial Commission P.O. Box 83720 Boise, ID 83720-0041 (208) 334-6080 State of Idaho CRIME VICTIM'S APPLICATION FOR COMPENSATION This form is not for the primary victim. This form is for: parent, spouse, sibling, child, grandchild and grandparent of primary victim. Print or type -- Then mail to the address above. Name of Family Member Seeking Benefits FAMILY ASSISTANCE APPLICATION Social Security # City State Zip Address Date of Birth Telephone Marital Status Sex Relationship to Primary Victim Name of Primary Victim Date of Crime County Where Crime Occurred Was a claim filed for Crime Victims benefits on the primary victim? Yes Type of crime: Homicide Kidnapping Sexually abused minor Physical child abuse No Date filed: Sexual assault (adult only) Domestic violence If none, do you need a referral? Yes No Name of your mental health counselor Address of mental health counselor: Date treatment began: Check other sources which may be available to pay for your counseling: a. Medical Insurance e. Employee Assistance Program b. Medicare f. Other (Explain) c. Medicaid g. None d. Veteran's Benefits CVCP USE ONLY (If any of the above resources are checked, give company name, address and policy numbers below:) (If Medicaid/Medicare is checked, please list dates you applied for benefits:) YOU MUST USE COLLATERAL SOURCES SUCH AS MEDICAL INSURANCE POLICIES AND GOVERNMENT BENEFITS SUCH AS MEDICAID BEFORE YOU CAN RECEIVE CRIME VICTIMS FUNDS. The filing of this claim form is authorization for the release of any medical/counseling records to the Crime Victims Compensation Program from the date of the crime. I declare under penalty of perjury that the foregoing information is true and complete. Signature of legal guardian (Required if secondary victim is a minor) CVCP USE ONLY CLAIM NUMBER Date Signature Date CV-02 (2/06) American LegalNet, Inc. www.FormsWorkFlow.com
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