Form JD-VS-8PI "Personal Injury Compensation - Application" - Connecticut

What Is Form JD-VS-8PI?

This is a legal form that was released by the Connecticut Judicial Branch - a government authority operating within Connecticut. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2017;
  • The latest edition provided by the Connecticut Judicial Branch;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a fillable version of Form JD-VS-8PI by clicking the link below or browse more documents and templates provided by the Connecticut Judicial Branch.

ADVERTISEMENT
ADVERTISEMENT

Download Form JD-VS-8PI "Personal Injury Compensation - Application" - Connecticut

1260 times
Rate (4.5 / 5) 88 votes
PERSONAL INJURY
APPLICATION
JD-VS-8PI Rev. 10/17
We are here to help. If you have any questions about filling out this application or the Victim Compensation Program,
please call us 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, you may miss important deadlines set by state law or your claim may be closed.
SECTION 1 –
VICTIM INFORMATION
The person who was physically injured because of the crime.
Name of victim (first, middle, last)
Birth date (mm/dd/yyyy)
Age
Address
City
State
Zip
Daytime phone number
Cell phone
Email
Gender:  female  male  other
Primary language spoken
SECTION 2 –
CLAIMANT INFORMATION
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.
How is the claimant related to the victim?
 child  spouse
 parent
 grandchild  grandparent  spouse’s parent
 stepparent
 brother  sister
 half-brother  half-sister  step-child  adopted child  party to a civil union
 aunt
 uncle
 niece
 nephew  other
Name of claimant (first, middle, last)
Birth date (mm/dd/yyyy)
Age
Address
City
State
Zip
Daytime phone number
Cell phone
Email
Gender:  female
 male
 other
Primary language spoken
FOR OFFICE USE ONLY Claim Number
Claims Examiner
PERSONAL INJURY
APPLICATION
JD-VS-8PI Rev. 10/17
We are here to help. If you have any questions about filling out this application or the Victim Compensation Program,
please call us 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, you may miss important deadlines set by state law or your claim may be closed.
SECTION 1 –
VICTIM INFORMATION
The person who was physically injured because of the crime.
Name of victim (first, middle, last)
Birth date (mm/dd/yyyy)
Age
Address
City
State
Zip
Daytime phone number
Cell phone
Email
Gender:  female  male  other
Primary language spoken
SECTION 2 –
CLAIMANT INFORMATION
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.
How is the claimant related to the victim?
 child  spouse
 parent
 grandchild  grandparent  spouse’s parent
 stepparent
 brother  sister
 half-brother  half-sister  step-child  adopted child  party to a civil union
 aunt
 uncle
 niece
 nephew  other
Name of claimant (first, middle, last)
Birth date (mm/dd/yyyy)
Age
Address
City
State
Zip
Daytime phone number
Cell phone
Email
Gender:  female
 male
 other
Primary language spoken
FOR OFFICE USE ONLY Claim Number
Claims Examiner
SECTION 3 –
PARENT/LEGAL GUARDIAN/CONSERVATOR INFORMATION
This section is for parents or legal guardians of children under 18 years old and legal guardians or conservators for an
incapacitated adult.
 parent
 adoptive parent
Relationship:
 legal guardian  conservator
Name of parent/legal guardian/conservator (first, middle, last)
Address
City
State
Zip
Daytime phone number
Cell phone
Email
Gender:  female
 male
 other
Primary language spoken
SECTION 4 –
ATTORNEY REPRESENTATION
You do not need an attorney to receive victim compensation. If you do have an attorney, please check if the attorney is
helping you with your claim, a civil lawsuit, or both and provide the attorney’s contact information.
 Representing me on this application  Representing me in a civil lawsuit
Name of attorney (first, middle, last)
Name of firm
Address
City
State
Zip
Work telephone
Fax number
Email
Juris number
SECTION 5 –
PERMISSION TO CONTACT OR SPEAK WITH ANOTHER PERSON
Please check if you are giving OVS permission to contact someone if we can’t reach you, permission to speak with
someone about your claim, or both, and provide that person’s contact information.
 Permission to contact, if OVS can’t reach me  Permission to speak with about my claim
Name of person (first, middle, last)
How do you know this person?
Address
City
State
Zip
Daytime phone number
Cell phone
Email
SECTION 6 –
STATISTICAL INFORMATION
It is your choice to answer these questions. This information is used in state and federal reports.
Would you describe the victim as:
 american indian/alaska native
 asian
 black/african american
 hispanic/latino/latina
 native hawaiian/other pacific islander
 white non-latino/caucasian
 other race
Was the victim disabled before the crime?  yes
 no
 don’t know
Was the victim disabled after the crime?  yes
 no
 don’t know
How did you find out about the Victim Compensation Program:
SECTION 7 –
CRIME INFORMATION
If the crime involved sexual assault or human trafficking, please do not fill out this section but answer the questions
in Section 7a.
Date of crime
Address and city where crime happened
Type of crime:  physical assault  robbery with injury  driving under the influence (dui)  evading (hit and run)
 other crime causing physical injury
Briefly describe the crime and physical injuries:
Date crime reported to police: Was the crime reported within 5 days?  yes  no (if no, please explain):
Police department
Name of officer investigating the crime
Police report number
If the crime was domestic violence and not reported to police, please check which professional you told about the assault:
 judge (if the judge gave you a restraining or civil protection order, please attach a copy of the application or affidavit.)
 domestic violence counselor
 sexual assault counselor
 other
SECTION 7a –
SEXUAL ASSAULT OR HUMAN TRAFFICKING CRIMES
Type of crime:  sexual assault  forced labor  other
If a sexual assault, did you have a sexual assault medical examination and evidence collected?  yes  no
If yes, name of health care facility
Date of examination
Please check which professional you told about the assault:
 judge (if the judge gave you a restraining or civil protection order, please attach a copy of the application or affidavit.)
 sexual assault or domestic violence counselor  medical professional  mental health professional  police
 Department of Children and Families employee  school professional  other
Name of the person you told about the assault
Title
Date you told that person
Address (street, city, state, zip)
Telephone
SECTION 8 –
OFFENDER INFORMATION
Was someone arrested for the crime?
 yes
 no  don’t know
Name of person arrested, if known
Did the offender go to court?
 yes
 no
 don’t know
If yes, city where courthouse is located
Docket number, if known:
Did the court order the offender to pay for your crime-related expenses (restitution)?
 yes
 no
 don’t know
SECTION 9 –
CRIME-RELATED EXPENSES AND FINANCIAL RESOURCES
Please check the box next to the compensation benefit you are applying for, the boxes next to the financial resources you
have available to you, and fill out the information requested. You must contact us if any of the financial resources not
checked become available to you. If you do not have any crime-related expenses at this time, it is important that you still
submit the application in case you need financial help in the future.
NO EXPENSES AT THIS TIME (please skip to Section 10 and sign the application)
MEDICAL, MENTAL HEALTH, DENTAL, AND PRESCRIPTION EXPENSES
Please list the names of all providers who treated you and provide copies of crime-related bills, prescription printouts
for co-pay amounts, and insurance benefit statements, if available.
Provider Name
Address (street, city, state, zip)
Telephone
Financial Resources
Insurance Company
Member Number
Telephone
 Dental Insurance
 Department of Social Services
(Medicaid/Husky)
 Health Insurance
(primary)
 Health Insurance
(secondary)
 Medicare
 Supplemental Insurance
(accident/illness)
 Vehicle Insurance
(for crimes involving vehicles)
 Veterans Health Administration
 Workers’ Compensation
(for crimes at work)
 Donations
(example GoFundMe)
CRIME SCENE CLEAN-UP EXPENSES (Maximum benefit $1,000)
Please fill out this section if you paid all or part of the crime scene clean-up expenses and provide copies of bills and
receipts, if available. Expenses may include biohazard cleaning, replacing or repairing damaged locks, windows, doors,
and alarm systems.
Provider Name
Address (street, city, state, zip)
Telephone
Financial Resources
Insurance Company
Policy Number
Telephone
 Homeowners’ Insurance
 Renters’ Insurance
 Vehicle Insurance
(for crimes involving vehicles)
SECTION 9 –
CRIME-RELATED EXPENSES AND FINANCIAL RESOURCES
(continued)
EXPENSES TO ATTEND ADULT COURT PROCEEDINGS
Please fill out this section if you have or will have expenses to attend adult court proceedings. The relatives of the victim
that are eligible for this benefit include the victim’s child (natural, adopted, step), spouse, parent, spouse’s parents,
grandchild, grandparent, stepparent, brother and sister (natural and half), aunt, uncle, niece, and nephew.
Please check the type of expenses and losses you have or will have to attend court proceedings:
 travel expenses (includes mileage reimbursement)
 l ost wages (please fill out the information about your employer in the Wage Loss section. OVS will contact your
employer for the dates absent and salary and benefit information. If you have a concern about this, please call us.)
Please list the dates you attended or will attend court proceedings:
WAGE LOSS (employed or self-employed)
If you were employed or self-employed at the time of the crime and are applying for wage loss, it is important for you to
know that we can only consider taxable income. Please check if you are self-employed or if you are giving OVS permission
to contact your employer for the dates you were absent and salary and benefit information.
 I am self-employed (a claims examiner will contact you)
 You have my permission to contact my employer (please fill out your employer information)
 You do not have my permission to contact my employer (a claims examiner will contact you)
Name of employer
Contact name
Telephone
Address
City
State
Zip
Hours worked per week
Wages per hour
Tips, bonuses per week
Dates absent because of crime-related injuries or care to victim
If you missed more than 1 week of work, you must provide a note from the treating health care provider listing the days
you were absent from work because of the crime-related injuries. Please include a copy of the note with this application or
fill out the information below:
Name of health care provider
Address (street, city, state, zip)
Telephone
Financial Resources
Insurance Company
Member Number
Telephone
 Department of Social Services
(financial)
 Disability Insurance
 Life Insurance – Disability Rider
 Police/Firefighters Insurance
 Social Security Disability
 Supplemental Insurance
(accidental/illness)
 Unemployment Compensation
 Vehicle Insurance
(for crimes involving vehicles)
 Workers’ Compensation
(for crimes at work)
 Donations
(example GoFundMe)
Page of 6