Fillable Printable Form 800-120-000
Fillable Printable Form 800-120-000
Form 800-120-000
For Office Use Only:
Claim No.________________
Department of Labor and Industries
Crime Victims Compensation Program
PO Box 44520
Olympia WA 98504-4520
Email:
CrimeVictimsProgram[email protected]v
Fax: 360-902-5333
Crime Victim’s Application for
Benefits – Homicide Claims
Visit our website at www.Lni.wa.gov/CrimeVictims
Homicide Victim Information
Victim’s Name (First, Middle, Last)
Date of Crime
Date of Death
Social Security Number (Optional)
Homicide Victim’s Gender
Male Female
Date of Birth (mm/dd/yyyy)
Marital Status
Married
Domestic Partner
Single
Divorced
Separated
Spouse’s or Partner’s Name
Spouse’s or Partner’s Email Address
Spouse’s or Partner’s Mailing Address
City State Zip Code
Spouse’s or Partner’s Telephone Number
Dependent Children
List the homicide victim’s children, including any unborn children. If there are multiple children with different
guardians, provide each guardian’s contact information. If more space is needed, attach a separate sheet of
paper.
Name
Birth Date
Guardian Name
1.
2.
3.
4.
Address of Children’s Legal Guardian
City
State
Zip Code
Telephone Number of Children’s Legal Guardian
Email of Children’s Legal Guardian
Other Information
What was the homicide victim’s country of origin?
What was the victim’s ethnicity?
African American
Asian
Pacific Islander
Caucasian
Hispanic
Native American
Other:
F800-120-000 Crime Victim’s Application for Benefits – Homicide Claims 01-2016 Page 1 of 5 Index: APP
For Office Use Only:
Claim No.________________
Person Applying for Benefits of the Homicide Victim
Name of Person Applying on Behalf of the Deceased Victim
Preferred Language (if not English)
Relationship to Deceased Victim
Mailing Address
City
State
Zip Code
Telephone Number
Email Address
How did you find out about the Crime Victim’s Program? (Check the box that applies)
Police/Law Enforcement
Prosecutor’s Office
Victim Assistance Program Advocate
Victim Witness Service
Health Care Provider
Hospital
Other:
What benefits are you applying for?
Medical
Dental
Mental Health
Wage Loss
Burial Benefits
Grief Counseling
Medical Treatment Related to the Crime Injury
If the homicide victim received medical treatment prior to death for the crime injury, please list the health care
provider(s) below. Attach additional pages if needed.
Provider Name
Telephone Number
City
Crime Information
Date of Incident (mm/dd/yyyy)
Date Reported (mm/dd/yyyy)
Time
AM PM
Date of Death (mm/dd/yyyy)
Crime Location Address
City
State
Zip Code
Did the crime occur on the job?
Yes
No
Name of Law Enforcement Agency (Check the box below for the type of agency)
Police
Washington State Patrol
Federal Bureau of Investigations
Sheriff
Tribal Police
Officer’s Name
Telephone Number
Report Number
Type of Crime
Murder
Vehicular Assault
Brief Description of the Crime
Weapon Used
Area of the Body Injured
Offender’s Name
F800-120-000 Crime Victim’s Application for Benefits – Homicide Claims 01-2016 Page 2 of 5 Index: APP
For Office Use Only:
Claim No.________________
Attorney Information
Is there any attorney representing the estate of the homicide victim? Yes No
Attorney Name
Email Address
Telephone Number
Address
City
State
Zip Code
Wage Information
Only the spouse, domestic partner, or minor children may be eligible for wage replacement benefits. For these
benefits, the homicide victim must have been employed on the date of the crime.
Please f
ill out this section only if the homicide victim was employed or self-employed at the time of the crime
and the spouse, domestic partner, or minor children are applying for wage loss benefits. We may contact the
employer if necessary. If you have concerns about this, please call us.
Was the victim employed on the date of the crime?
Yes
No
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
Rate of pay
$
Hour Day Week Month
Hours worked per day
Days worked per week
Additional Earnings
$
Additional Earning From
Piecework Tips Commission Bonuses
Annual Income Level (Select One)
$0 – $20,000
$20,001 – $50,000
$50,001 – $75,000
$75,001 – $100,000
$100,000 or more
F800-120-000 Crime Victim’s Application for Benefits – Homicide Claims 01-2016 Page 3 of 5 Index: APP
For Office Use Only:
Claim No.________________
Insurance Information
Providing this information will ensure proper payment of medical expenses.
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 your insurance pays. Attach additional pages if needed.
Did the homicide victim have insurance? Yes No
If yes, list all available coverage including: health insurance, HCA/Medicaid, Medicare, Veterans, Social
Security, DSHS/public assistance, workers’ compensation, Indian health, vehicle insurance (victim and
offender), life insurance, home owner’s insurance, or renter’s insurance. Attach additional pages if needed.
Insurance Company Name
Policy Holder Name
Telephone Number
Provide one of the following: Policyholder ID, Group No., or SSN
Insurance Company Name
Policy Holder Name
Telephone Number
Provide one of the following: Policyholder ID, Group No., or SSN
Funeral/Burial Expenses
To receive payment, send an itemized statement within 12 months of the homicide or the release of the remains.
Name of Funeral Home
Telephone Number
Funeral Home’s Address
City
State
Zip Code
Notes
F800-120-000 Crime Victim’s Application for Benefits – Homicide Claims 01-2016 Page 4 of 5 Index: APP
For Office Use Only:
Claim No.________________
Authorization to Release Confidential Information
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 the
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 unders
tand 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 other government or private agency, I shall
reimburse the State of Washington Crime Victims Compensation Program for any compensation paid out
under this claim.
By si
gning below, I certify under penalty of perjury under the laws of the State of Washington that the foregoing
is true and correct.
If 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 guardianship documentation.
Print Name
Signature
Date
Note to
Medical Providers:
RCW 7.68.145: Release of information in performance of official duties.
Notwi
thstanding any other provision of law, all law enforcement, criminal justice, or other government 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 CRF §
164.502(b)(2)(v).
F800-120-000 Crime Victim’s Application for Benefits – Homicide Claims 01-2016 Page 5 of 5 Index: APP
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