Crime Victims' Application For Benefits Injury Claims (F800 042 000) F800 000
User Manual: F800
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For Office Use Only:
Claim No.________________
F800-042-000 Crime Victim’s Application for Benefits 07-2017 Index: APP
Crime Victims Compensation Program
PO Box 44520
Olympia WA 98504-4520
Crime Victim’s Application for
Benefits ― Injury Claims
Email: CrimeVictimsProgramM@Lni.wa.gov
Fax: 360-902-5333
Visit our website at www.Lni.wa.gov/CrimeVictims for information
Victim Information
Preferred Language (If not English)
Email Address
Name (First, Middle, Last)
Social Security Number (Optional)
Telephone Number
Date of Birth (mm/dd/yyyy)
Sex
Male Female
Mailing Address
City
State
Zip Code
If the victim is a minor, provide the full name of the parent or guardian applying on the victim’s behalf.
Name
Relationship
Who has permission to call CVCP on your behalf?
Name
Relationship
Telephone Number
Email Address
Other Information
How did you find out about the CVCP? Check the box that applies.
Police/Law Enforcement
Prosecutor’s Office
Victim Assistance Program Advocate
Victim Witness Service
Hospital
Health Care Provider
Other:
What is your marital status? Check the box that applies.
Married
Single
Domestic Partner
Divorced
Separated
What is your country of origin?
What is your ethnicity? Check the box that applies.
African American
Asian
Caucasian
Hispanic
Native American
Pacific Islander
Other:
Do you have a disability?
No Yes
Was the disability caused by the crime?
No Yes
Is the disability:
Physical Mental Both
What benefits are you applying for?
Medical Dental Mental Health Wage Loss
For Office Use Only:
Claim No.________________
F800-042-000 Crime Victim’s Application for Benefits 07-2017 Index: APP
Crime Information
NOTE: The crime must be reported to a police agency
Date of Incident (mm/dd/yyyy)
Date Reported (mm/dd/yyyy)
Time Incident Occurred
AM PM
Crime Location Address
City
State
Zip Code
Did the crime occur on the job?
No Yes
What law enforcement agency did you report the crime to?
Check the box that applies:
Police
Washington State Patrol
Federal Bureau of Investigations
Sheriff
Tribal Police
Officer’s Name
Telephone Number
Report Number
Type of Crime
Assault
Civil Commitment
DUI
Failure to Secure Load
Sexual Assault
Domestic Violence
Vehicular Assault
Robbery/Burglary
Brief Description of the Crime
Weapon Used
Area of Body Injured
Offender’s Name
Was the offender living with you when the incident occurred?
No Yes
If you were involved in a civil commitment proceeding of a sexually violent predator, when were you contacted about the proceedings?
Date
Who Contacted You
Telephone Number
Have you filed or do you intent to file a civil suit?
No Yes Unsure
Attorney Information
Do you have an attorney representing you?
No Yes
If you have an attorney representing you, check the box that applies:
Attorney is representing me for a personal injury claim (auto-insurance) or lawsuit
Attorney is representing me for both the crime victim claim and a personal injury claim (auto-insurance) or
lawsuit
NOTE: If the attorney represents you on your crime victim claim, all department correspondence will go to your attorney.
Attorney Name
Email Address
Telephone Number
Address
City
State
Zip Code
For Office Use Only:
Claim No.________________
F800-042-000 Crime Victim’s Application for Benefits 07-2017 Index: APP
Wage Information
For wage loss benefits, you must have been employed on the date of the injury or employed in the six months
before the injury.
Please fill out this section only if you were employed or self-employed at the time of the crime or employed in
the six months before the date of the crime and are applying for wage loss benefits. We may contact your
employer if necessary. If you have concerns about this, please call us.
Were your employed on the date of the crime?
No Yes
Were you employed in the six months before the crime?
No Yes
If yes and you are requesting wage replacement benefits, provide the following employer information
Employer Name
Contact Name
Employer Address
City
State
Zip Code
Telephone Number
Date Last Worked
Have You Returned to Work?
No Yes
If yes, date you returned to work
Rate of Pay
$
Hour
Day
Week
Month
Hours Worked Per Day
Days Worker Per Week
Additional Earning
$
Additional Earning From
Piecework Tips Commission Bonuses
Did you use sick/vacation leave or disability benefits?
No Yes
Annual Income Level. Check the box that applies to you
$0 ― $20,000
$20,001 ― $50,000
$50,001 ― $75,000
$75,001 ― $100,000
$100,000 or more
Insurance Information
Providing this information will ensure proper payment of medical expenses.
Note: You are required to use any available private or public insurance you have first. The Crime Victims
Compensation Program is the last payer of benefits. If you have private or public insurance, your provider must
bill your insurer first. Please provide accurate information about any insurance you have to ensure bills are
paid correctly.
Do you have insurance? If yes, provide the information requested below.
No Yes
The Crime Victims Compensation Program is the payer of last resort. Providers should bill your primary
insurance first. Please list all available coverage to include: health insurance, dental insurance, vision
insurance, HCA/Medicaid, Veteran, Social Security, DSHS/public assistance, workers’ compensation, Indian
Health, automobile insurance (victim and offender), motorcycle insurance, life insurance, home insurance,
renter’s insurance. CVCP can only pay benefits after you insurance pays. Attach additional pages if needed.
Insurance Company Name
Telephone Number
Policy Holder Name
Provide one of the following: Policyholder ID, Group No., or SSN
Date of Eligibility
Insurance Company Name
Telephone Number
Policy Holder Name
Provide one of the following: Policyholder ID, Group No., or SSN
Date of Eligibility
For Office Use Only:
Claim No.________________
F800-042-000 Crime Victim’s Application for Benefits 07-2017 Index: APP
Provider Information
If you have already seen a medical or other provider, or are completing this form in a medical office or hospital,
please ask the medical professional seeing you to complete the section below.
Provider Name
Provider’s L&I Provider Number
Facility Name
Telephone Number
Address
City
State
Zip Code
Date Patient First Treated for Crime Injury
Diagnosis Codes
Description of Injury
Will the patient lose time from work due to their injuries?
No Yes
Wage Loss Certified
From:
To:
Provider’s Signature
Date
For Office Use Only:
Claim No.________________
F800-042-000 Crime Victim’s Application for Benefits 07-2017 Index: APP
Authorization to Release Confidential Information
NOTE: The victim or legal guardian must sign this form to be valid
I hereby authorize any hospital, physician, funeral director, or other person who provided services; any
employer of the victim; any law enforcement agency or other government agency, including state and federal
services; any and all insurance companies or any other agency having knowledge necessary for this
determination of eligibility of this claim for benefits to furnish to the Crime Victims Compensation Program or its
representatives any and all information, including but not limited to documents generated by themselves and
others, specifically pertaining to this claim. Other information may be required to determine whether conditions
are related to the crime. I understand this may include results of HIV and other sexually transmitted disease
testing, alcohol, drug, and psychiatric treatment.
I understand that if I receive any recovery of my losses through court-imposed restitution or civil lawsuit against
the offender, any insurance settlement, or moneys from any government or private agency, I shall reimburse
the State of Washington Crime Victims Compensation Program for any compensation paid out under this claim.
By signing below, I certify under penalty of perjury under the laws of the State of Washington that the foregoing
is true and correct.
If the victim is a minor, parent or legal guardian, please sign. If you are the legal guardian, please send the
Crime Victims Compensation Program a copy of the guardianship documentation.
Print Name
Signature
Date
Note to Medical Providers:
RCW 7.68.145: Release of information in performance of official duties.
Notwithstanding any other provision of law, all law enforcement, criminal justice, or other governmental agencies, or hospital; any
physician or other practitioner of the healing arts; or any other organization or person having possession or control of any investigative
or other information pertaining to any alleged criminal act or victim concerning which a claim for benefits has been filed under this
chapter, shall, upon request, make available to and allow the reproduction of any such information by the section of the department
administering this chapter or other public employees in their performance of their official duties under this chapter.
Your disclosure of this information is allowed under the Health Insurance Portability and Accounting Act (HIPAA). This
disclosure is required by Washington State law. You may disclose health information under HIPAA without an authorization if that
disclosure is required by law, 45 CRF § 164.512(a). Also, since your disclosure is required by law it is not subject to HIPAA’s minimum
necessary standard, 45 CFR § 164.502(b)(2)(v).
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