Connecticut > Statewide > Victim Services
Personal Injury Compensation JD-VS-8PI - Connecticut
| Personal Injury Compensation Form. This is a Connecticut form and can be used in Victim Services Statewide . |
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PERSONAL INJURY COMPENSATION APPLICATION JD-VS-8PI 10/12 We are here to help. If you have any questions about filling out this application or the Compensation Program, please call us toll-free at 1-888-286-7347. Please know that it is important that you tell us if your contact information changes. If we cannot reach you, your claim may be closed or you may miss important deadlines set by state law. SECTION 1 - VICTIM INFORMATION The victim is the person who was physically injured because of the crime. Parents and legal guardians of a minor child (under 18 years old) and legal guardians of an incapacitated adult must also fill out Section 3. A separate application must be filled out for each victim who was physically injured. Name of victim (last, first, middle) Address Home telephone Primary language spoken Work telephone Birth date City Cell phone Gender: m Female Email m Male Age State Zip m Other SECTION 2 - CLAIMANT INFORMATION The claimant is the person who has expenses because of the crime. If the victim and the claimant are the same person, you do not have to fill out this section. Parents and legal guardians of a minor child (under 18 years old) and legal guardians of an incapacitated adult must also fill out Section 3. Name of claimant (last, first, middle) Address Home telephone Primary language spoken Work telephone Birth date City Cell phone Gender: m Female Email m Male m Other Age State Zip Relationship to victim: m child m spouse m parent m grandchild m stepchild m grandparent m spouse's parent m stepparent m brother m sister m half-brother m half-sister m adopted child m party to a civil union m other An adult victim/claimant, the parent/legal guardian of a minor child (under 18 years old), or the legal guardian of an incapacitated adult must sign Section 10 of this application. Applications that are not signed will be returned. American LegalNet, Inc. www.FormsWorkFlow.com SECTION 3 - PARENT/LEGAL GUARDIAN INFORMATION This section is for parents and legal guardians of children under 18 years old and legal guardians of an incapacitated adult. If you have your own expenses because of the crime, please fill out another application and list yourself as the claimant. (Legal guardians or conservators must provide a copy of the court order.) Name of parent or legal guardian (last, first, middle) Address Home telephone Primary language spoken Work telephone How are you related to the victim/claimant? City Cell phone Gender: m Female Email m Male m Other State Zip SECTION 4 - ATTORNEY REPRESENTATION Please check if an attorney is representing you on this application, a civil lawsuit, or both and provide the attorney's contact information. m Representing me on this application m Representing me in a civil lawsuit Name of attorney (last, first, middle) Address Work telephone Fax number Name of firm City Juris number State Zip SECTION 5 - STATISTICAL INFORMATION How did you find out about the Victim Compensation Program? m community advocate m family member m friend/acquaintance m hospital m Infoline 211 m medical provider m mental health provider m Office of Adult Probation m OVS victim advocate m OVS web page m police m poster/brochure m private attorney m prosecutor/state's attorney m public service announcement m telephone book m other Statistics are voluntary and needed for federal reporting requirements. m white m hispanic m asian m other m black/african american m native hawaiian/pacific islander m american indian/alaskan native m unknown m yes m no Was the victim disabled before the crime? American LegalNet, Inc. www.FormsWorkFlow.com SECTION 6 - CRIME INFORMATION If the crime was a sexual assault, please do not fill out this section but answer the questions in Section 6a. This section must be filled out for all other crimes. Type of crime: m assault m robbery with injury m dui m hit and run m other Briefly describe the crime and physical injuries: Date of crime Date crime was reported to police Police department incident number Address and city or town where crime happened Police department crime was reported to Name of police officer investigating the crime Was the crime reported to the police within 5 days? m yes m no (If no, please explain) Was someone arrested for the crime? m yes m no m unknown Name of person(s) arrested, if known Did the person(s) arrested go to court? m yes m no m unknown If yes, court location Docket number, if known SECTION 6a - SEXUAL ASSAULT CRIMES Date of crime Address and city or town where crime happened m no Date of examination Did you go to a hospital for a sexual assault medical examination and evidence collection? m yes If yes, name of hospital or healthcare facility Please check which professional you told about the sexual assault: m alcohol and drug counselor m clinical social worker m counselor m emergency medical services provider m marriage and family therapist m mental health professional m nurse (advanced practice, practical, or registered) m physician or physician assistant m psychologist m resident physician or intern at a Connecticut hospital m sexual assault or battered women's counselor m surgeon m employee of Department of Children and Families m police officer Name of the person you told about the assault Address Telephone number Title City Date of disclosure State Zip American LegalNet, Inc. www.FormsWorkFlow.com SECTION 7 - CRIME EXPENSES Please list all of the hospitals, doctors, dentists, counselors, ambulance services, radiology services, and others who provided treatment or services because of the crime and list the prescriptions (drugs and eyeglasses) you were given because of it (attach additional pages, if needed) and include copies of any crime related bills. Provider Telephone Address City State Zip SECTION 8 - EMPLOYMENT INFORMATION Please fill out this section if you were employed or self-employed at the time of the crime and are applying for lost wages. If self-employed, attach a copy of your tax return and W2 or 1099 form for the year of the crime. If you have not filed your taxes before completing this application, forward the information for the year before the crime. Please note that we can only consider taxable income. We will contact your employer for dates absent, salary, and benefit information. If you have a concern about this, please call us. If you missed more than 1 week of work, please provide a doctor's note. Name of employer Contact name Telephone number Address City State Zip Hours w
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