"Application for Compensation" - New York

Application for Compensation is a legal document that was released by the New York State Office of Victim Services - a government authority operating within New York.

Form Details:

  • Released on September 1, 2016;
  • The latest edition currently provided by the New York State Office of Victim Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the New York State Office of Victim Services.

ADVERTISEMENT
ADVERTISEMENT

Download "Application for Compensation" - New York

237 times
Rate (4.7 / 5) 14 votes
Claim Application and
Instructions
How to Apply for Compensation
Who can apply for compensation?
Innocent victims of crime, certain relatives, dependents,
What if I don’t have some of the papers OVS
legal guardians and eligible Good Samaritans can apply
needs?
to the Office of Victim Services (OVS) for compensation
of out-of-pocket expenses not covered by insurance or
Send your application in right away. You can send the
other resources.
other documents later.
What kind of expenses can I get compensated
What if my property was lost, damaged or
for?
destroyed because of the crime?
OVS offers compensation related to personal injury,
If you are under 18, 60 or over, disabled or were injured,
death and loss of essential personal property.
you may apply for benefits to replace your essential
personal property or cash that was not covered by any
The specific expenses OVS may cover include:
other resource.
Medical, pharmacy and counseling expenses
Loss of Essential Personal Property (up to $500,
Essential means necessary for your health and welfare,
including $100 for cash)
like eyeglasses and clothes.
Burial or Funeral Expenses (up to $6,000)
What if I move?
Lost Wages or Lost Support (up to $30,000)
Send OVS a signed letter right away. Tell us your new
(Parents or guardians of hospitalized minor children
address and phone number. Also let us know if your
may be eligible for this benefit.)
email address changes.
Transportation (court/medical)
Who can sign the claim?
Occupational/Vocational Rehabilitation
Generally, the victim must sign the claim. However, if the
Security Devices and DV Shelter Costs
victim is under 18, or is physically or mentally incapable
Crime scene clean-up (up to $2,500)
of signing, then the legal guardian (the person receiving
Good Samaritan property losses (up to $5,000)
the benefits) must fill out section 2 of the claim and sign
Moving expenses (up to $2,500)
the claim.
If the victim died, the person asking for benefits must fill out
How do I ask for compensation?
section 2 of the claim and sign the claim.
Send us your completed OVS application along with
copies of:
Is there another way to apply?
Police reports
Yes. Visit ovs.ny.gov to access the secure Victim Service
Medical bills
Portal (VSP) and file an application on line.
Correspondence with insurance companies
or benefits plan saying if they will cover your loss
Do I have to fill out the attached HIPPA form?
Insurance cards
Yes. Fill out one HIPAA form for each service provider.
Receipts for essential personal property
You can photocopy a blank form to make extra copies.
Death certificate and funeral contract
Victim’s birth certificate
Proof of age (driver’s license, birth certificate etc.)
Legal guardianship papers
80 S. Swan Street
55 Hanson Place
Albany, NY 12210-8002
Brooklyn, NY 11217-1523
(518) 457-8727
(718) 923-4325
ovs.ny.gov
800-247-8035
Rev. September 2016
Claim Application and
Instructions
How to Apply for Compensation
Who can apply for compensation?
Innocent victims of crime, certain relatives, dependents,
What if I don’t have some of the papers OVS
legal guardians and eligible Good Samaritans can apply
needs?
to the Office of Victim Services (OVS) for compensation
of out-of-pocket expenses not covered by insurance or
Send your application in right away. You can send the
other resources.
other documents later.
What kind of expenses can I get compensated
What if my property was lost, damaged or
for?
destroyed because of the crime?
OVS offers compensation related to personal injury,
If you are under 18, 60 or over, disabled or were injured,
death and loss of essential personal property.
you may apply for benefits to replace your essential
personal property or cash that was not covered by any
The specific expenses OVS may cover include:
other resource.
Medical, pharmacy and counseling expenses
Loss of Essential Personal Property (up to $500,
Essential means necessary for your health and welfare,
including $100 for cash)
like eyeglasses and clothes.
Burial or Funeral Expenses (up to $6,000)
What if I move?
Lost Wages or Lost Support (up to $30,000)
Send OVS a signed letter right away. Tell us your new
(Parents or guardians of hospitalized minor children
address and phone number. Also let us know if your
may be eligible for this benefit.)
email address changes.
Transportation (court/medical)
Who can sign the claim?
Occupational/Vocational Rehabilitation
Generally, the victim must sign the claim. However, if the
Security Devices and DV Shelter Costs
victim is under 18, or is physically or mentally incapable
Crime scene clean-up (up to $2,500)
of signing, then the legal guardian (the person receiving
Good Samaritan property losses (up to $5,000)
the benefits) must fill out section 2 of the claim and sign
Moving expenses (up to $2,500)
the claim.
If the victim died, the person asking for benefits must fill out
How do I ask for compensation?
section 2 of the claim and sign the claim.
Send us your completed OVS application along with
copies of:
Is there another way to apply?
Police reports
Yes. Visit ovs.ny.gov to access the secure Victim Service
Medical bills
Portal (VSP) and file an application on line.
Correspondence with insurance companies
or benefits plan saying if they will cover your loss
Do I have to fill out the attached HIPPA form?
Insurance cards
Yes. Fill out one HIPAA form for each service provider.
Receipts for essential personal property
You can photocopy a blank form to make extra copies.
Death certificate and funeral contract
Victim’s birth certificate
Proof of age (driver’s license, birth certificate etc.)
Legal guardianship papers
80 S. Swan Street
55 Hanson Place
Albany, NY 12210-8002
Brooklyn, NY 11217-1523
(518) 457-8727
(718) 923-4325
ovs.ny.gov
800-247-8035
Rev. September 2016
Court Ordered Restitution Information
What is restitution?
Restitution is compensation paid to a victim by the perpetrator of a criminal offense for the losses or injuries incurred as a
result of the criminal offense. It must be ordered by the Court at the time of sentencing, and is considered part of the sentence.
Restitution is NOT for payment of damages for future losses, mental anguish or “pain and suffering.”
When the District Attorney’s (DA) office advises the Court that you have requested restitution or when the victim impact
statement contained in the probation investigation report (pre-sentence, pre-plea or pre-disposition report) indicates that the
victim seeks restitution, the Court must order restitution unless the interests of justice dictate otherwise. When the judge does
not order restitution, the judge must clearly state his/her reasons on the record.
What can I request as restitution?
You can ask for any expense you incur as a result of the criminal offense – even for items the OVS may not be able to
reimburse. Restitution may include, but is not limited to, reimbursement for medical bills, counseling expenses, loss of
earnings, funeral expenses, insurance deductibles and the replacement of stolen or damaged property.
Who is entitled to restitution?
Anyone who has been the victim of a criminal offense and has suffered injuries, economic losses or damages can seek
restitution. Many times, victims who deserve restitution do not request it. This can occur because victims are not aware that
they are entitled to restitution, or do not know what steps to take to go about receiving the restitution they deserve.
How do I ask for restitution?
You should contact the DA’s office and advise them of the extent of your injury, your out-of-pocket losses and the amount of
damages you are requesting.
It is your responsibility
to give the police, DA and, upon request, the local probation department copies of the bills and
other documents showing the extent of your injuries, your out-of-pocket losses and the amount of damages you want
considered by the Court. Your claim for restitution will be included in any probation investigation report (pre-sentence, pre-plea
or pre-disposition report). Be sure to:
Keep accurate records such as original receipts of any expenses you have as a direct result of the criminal offense.
Give copies of these receipts to the police, DA and local probation department.
You need to clearly explain your need for restitution as soon as possible to the DA, the victim/witness advocate, and the
probation department. Plea agreements can occur within days of the actual criminal offense. If this information is not provided
before the plea agreement and sentencing, you may have to pursue the perpetrator in Civil Court.
The DA is under an obligation to petition the Court to order restitution on your behalf.
In all felony criminal cases, many misdemeanor criminal cases and all juvenile delinquency and persons in need of supervision
(PINS) cases, a pre-sentence or predisposition investigation report is required. The local probation department will contact you
about the issue of restitution as it pertains to your case.
How is restitution determined?
The amount of restitution is based on proof of your out-of-pocket losses incurred as a result of the criminal offense. The
perpetrator has a right to object to the amount of restitution. The Court may hold a hearing on the issue of restitution where the
Court may consider the perpetrator’s ability to pay. The DA’s office may contact you and ask you to testify at the restitution
hearing. If you have a concern about appearing personally in Court, you should explore alternatives with the DA assigned to
your case.
If the OVS has paid your bills, the Court may order that restitution payments be made to the OVS for those paid items. It is
important that you advise the DA’s Office that you filed a claim with the OVS.
If you filed a claim with the OVS, it is important that you advise the OVS if the Court orders the perpetrator to pay restitution.
Rev. September 2016
Read
Application for Compensation
How to Apply for
New York State Office of Victim Services
Compensation before
filling out this form.
Please print. Answer all questions. It is a crime to file a false claim!
Victim Assistance Program Use Only
OVS VAP ID#
Program Name/Phone
Advocate Name/Email
Tell us about the victim.
1
Last Name
First Name
MI
Social Security #
Date of Birth
Check here if you do not have one.
__ __ __
-
__ __
-
__ __ __ __
Mailing Address:
Street
Apt. # (or P.O. Box)
City
County
State (or Foreign Country)
Zip Code
Race/Ethnicity:
White
Black
Asian
Hispanic
American Indian/Alaskan Native
Pacific Islander/Native Hawaiian
Other
Multi-Race
Marital Status:
Single
Married
Divorced
Separated
Widowed
Lives with partner
Male
Female
Yes
No
Unknown
Gender:
Was the victim disabled at the time of the crime?
How did you first hear about the Office of Victim Services?
Police
Hospital
District Attorney
Victim Assistance Program
Radio/TV
Brochure/Poster
Internet
Other
2
If you are not the victim, and you are signing this claim, you are the claimant. Tell us about you. (See “Who can sign the claim?” on the
instructions page.)
Last Name
First Name
MI
Social Security #
Date of Birth
Check here if you do not have one.
__ __ __
-
__ __
-
__ __ __ __
Mailing Address:
Street
Apt. # (or P.O. Box)
City
County
State (or Foreign Country)
Zip Code
What is your relationship to the victim?
Check only one.
(
)
Parent
Spouse
Child
Legal Guardian
Attorney
Other
(Explain):
3
Tell us about the crime.
(Check only one.)
The victim was injured because of:
The victim died because of:
The victim lost essential personal property
Assault
Stalking
because of
:
Motor Vehicle (DUI/DWI)
Sexual Assault
Kidnapping
Burglary
Arson
Motor Vehicle (Other)
Child Physical Abuse/Neglect
Terrorism
Motor Vehicle (DUI/DWI)
Criminal
Terrorism
Child Sexual Abuse
Arson
Motor Vehicle (not DUI/DWI)
Mischief
Arson
Motor Vehicle (DUI/DWI)
Robbery
Human Trafficking
Fraud/Financial
Motor Vehicle (not DUI/DWI)
Human Trafficking
Human Trafficking
Robbery (No injury)
Crime
Child Pornography
Other Homicide
:
Other (Explain):
Other (Explain):
Where did the crime happen?
(Check only one.)
Work
Owned residence
Apt. Bldg.
Public Street
Subway/Bus
Parking Lot
Restaurant/Bar
School/School grounds
Shopping Mall
Other (Explain):
Was this a crime related to domestic violence?..................................................
Yes
No
Unknown
Was this a crime related to bullying?.................................................................
Yes
No
Unknown
Was this a crime related to elder abuse/neglect?...............................................
Yes
No
Unknown
Was this a hate crime?........................................................................................
Yes
No
Unknown
Was the victim driving a livery cab when the crime happened?
............................
Yes
No
Unknown
Was the victim’s property lost or damaged while trying to prevent or stop a
crime against someone else or while helping the authorities stop the crime?
....
Yes
No
Crime Report #:
Police or criminal justice agency reported
to:_____________________________
________________
County where crime happened:
Date of crime:
Date crime was reported:
______________
______________
If more than 7 days between the date of crime and date the crime was reported, explain why:
____________________________________
_______________________________________________________________________________________________________________________________________________________________
If more than 1 year between the date of crime and the date you are filing this claim, explain why:
________________________________
_______________________________________________________________________________________________________________________________________________________________
Describe the crime in your own words:
____________________________________________________________________________________________________________
Rev. September 2016
4
Tell us about the suspect.
Suspect’s name (if you know):
Has the suspect been arrested for this crime?
..................
Yes
No
Has the suspect been prosecuted for this crime?
.............
Yes
No
Not Yet
Does the suspect live in the same house as the victim
OR is the suspect a member of the victim’s family?
..........
Yes
No
Has the court issued an order of protection in this case?
..
Yes
No (If Yes, attach a copy.)
Has the DA asked the court to order restitution?
Yes
No
Not Yet
Did the court order the suspect to pay
restitution?........ ....
Yes (Amount $ _________ )
No
Not Yet
NOTE - If you are eligible for compensation, the OVS may be able to reimburse for the expenses listed below. These items should also be
requested as part of court ordered restitution. Applicants are encouraged to share this information with prosecutors if there is a criminal
case. See the Court Ordered Restitution Information page for important information about restitution.
5
Tell us about your expenses related to this crime.
(Check all that apply.)
Medical/Ambulance
Loss of Support
Lost Wages
Personal Transportation
Crime Scene Cleanup
(Death Claim Only)
DV Shelter
Medical/Counseling
Security Device/System
Vocational/Rehabilitation
Moving/Storage
Court
Counseling
Funeral/Burial
Essential Personal Property
Other (Explain):
6
List any essential personal property, like cash, eyeglasses, or clothing that needs to be replaced because of
this crime.
(If none, skip to 7.)
Describe what was lost/damaged:
Cost
Describe what was lost/damaged:
Cost
1.
$
4.
$
_________________________________________________
______________________
_________________________________________________
________________________
2.
$
5.
$
_________________________________________________
______________________
_________________________________________________
________________________
3.
$
6.
$
_________________________________________________
______________________
_________________________________________________
________________________
Homeowner/Renter Insurance Company
Policy or ID #
Deductible
$
Auto/Other Insurance Company
Policy or ID #
Deductible
$
— If there were no injuries and you are only asking for essential personal property benefits, skip to 15. —
7
Tell us about the victim’s or the parent’s employment and insurance for Lost Wages.
If you do not want us to contact your employer, you cannot ask to be reimbursed for Lost Wages. (Skip to 8.)
Was the victim/parent of hospitalized minor victim employed when the crime happened?
Yes
No (If No, skip to 8.)
Did the victim/parent of hospitalized minor victim miss work because of the crime?
Yes
No
Was the victim/parent self-employed?
Yes
No (If Yes, attach copies of last year’s federal tax return and all schedules.)
Employer’s Name, Address, and Phone #:
(
)
Employer
Street
City
State
Zip Code
Phone #
Other Employer’s Name, Address, and Phone #:
(
)
Employer
Street
City
State
Zip Code
Phone #
Name, Address, and Phone # of doctor who certified victim could not go to work:
(
)
Doctor
Street
City
State
Zip Code
Phone #
Tell us about any insurance company that will cover the victim’s lost time at work. (If none, write “None” below and skip to 8.)
Policy or ID # or “None”
Policy or ID # or “None”
1. Unemployment Insurance
5. Workers’ Compensation
2. Disability Insurance
6. Other insurance
3. Pension Plan
7. Social Security Benefits (ssn
SSN
required)
__ __ __
-
__ __
-
__ __ __ __
4.
8. SSI Benefits (ssn required)
SSN
Other insurance
__ __ __
-
__ __
-
__ __ __ __
8
If the victim died, fill out below if you have any burial expenses.
(If not, skip to 9.)
Also, attach a copy of the funeral home contract, other bills for burial expenses, and a photocopy of the Death Certificate, if you have them.
(
)
Phone #:
Name of Funeral Home:
_
Address:
Street
City
State
Zip Code
Rev. September 2016
Page 2 of 4
9
If the victim was injured or died because of this crime, fill out below.
Describe the victim’s injuries, briefly:
_______________________________________________________________________________________________________________________
Did the victim receive any medical treatment?
Yes
No (If No, skip to section10.)
Tell us about the health professionals who treated the victim for injuries related to this crime:
Full Name
Complete Address
Phone #
First Hospital
(
)
___________________________________
______________________________________________________________________
______
__________________
Other Hospital
(
)
___________________________________
______________________________________________________________________
______
__________________
First Doctor
(
)
(not in hospital)
___________________________________
______________________________________________________________________
______
__________________
Other Doctor
(
)
___________________________________
______________________________________________________________________
______
__________________
First Dentist
(
)
___________________________________
______________________________________________________________________
______
__________________
(
)
Victim’s Counselor
___________________________________
______________________________________________________________________
______
__________________
10
Tell us about the victim’s dependents or others who depended on the victim for support.
(If none, skip to 11.)
Name
Date of Birth
Relationship to Victim
Social Security #
Dependent
__ __ __
-
__ __
-
__ __ __ __
Address
Are you the legal
guardian?
Yes
No
Name
Date of Birth
Relationship to Victim
Social Security #
Other
__ __ __
-
__ __
-
__ __ __ __
Dependent
Address
Are you the legal
guardian?
Yes
No
Name
Date of Birth
Relationship to Victim
Social Security #
Other
__ __ __
-
__ __
-
__ __ __ __
Dependent
Address
Are you the legal
guardian?
Yes
No
If more than 3 dependents, attach a separate sheet and check here:
11 Did anyone besides the victim receive counseling because of this crime?
(If no, skip to 12.)
Who received counseling?
Relationship to Victim
Insurance company billed for counseling
Policy or ID #
Counselor’s name, address and phone #:
Who else received counseling?
Relationship to Victim
Insurance company billed for counseling
Policy or ID #
Counselor’s name, address and phone #:
If more than 2 people received counseling because of this crime, check here and attach a separate sheet to describe.
12
List any insurance covering the victim or the victim’s dependents. If no insurance, write “None” below.
If you have applied but are not covered yet, write “Pending” under Policy or ID #.
Name of person(s) covered by this insurance:
Policy or ID #
Primary Insurance Company
Major Medical Insurance Company
Other Insurance (Union, Dental, Vision, etc.)
Medicare
Medicaid
Workers’ Compensation
Auto Insurance
Other insurance
Page 3 of 4
Rev. September 2016