APPLICATION FOR COMPENSATION 1 SECTION A ... - Vintec

RETURN FORMS TO:Your Legal RepresentativesOrCriminal Injury Compensation UnitDepartment of Justice & Attorney-GeneralGPO Box 149BRISBANE QLD 4001APPLICATION FOR COMPENSATION 1(Where there is no Court Order)Criminal Offence Victims Act S.33Criminal Code S.663DSECTION A APPLICANT DETAILS (Victim or agent to complete)NameAddressSex Male Female Date of Birth:Have you madeany previousclaim(s)?Yes/No Date: Reference if any:Have there beenany order(s) to paycriminal injurycompensationmade against youat any stage?Yes/No Date: Reference if any:Are you aware ofany pendingapplications forcriminal injurycompensationagainst you?Yes/No Date: Reference if any:SECTION B DETAILS OF CRIME/OFFENCEDate of offenceLocation of offence(Town or city)Brief description of thecircumstances surrounding theoffence/s.1 All sections are to be completed unless otherwise stated and all requested information is to be attached.Failure to do this will prevent processing of the claim. Claims are limited to the prescribed amount from time totimePrepared and relevant as at November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on3239 6546 to ensure that its contents are current.Page 1 of 8

Date of offencePlease provide a copy of yourinitial statement to policefollowing the offence/s.Claims can only be made forpersonal offences such asassault, wounding and rape.Claims cannot be made forproperty offences such asstealing unless the offender alsoinflicted personal injuries.SECTION C DETAILS OF INJURIESBrief description of injuries.Details of hospitalisation &medical treatment received (ifany)Days in Hospital Name & Location of Hospital/Doctor TreatmentSECTION D MEDICO-LEGAL REPORT(S)NB: Medical Report(s) must be attached to this application (the cost of obtaining reports is not reimbursed).Name of hospital,doctor, dentistType of specialist(if applicable)Date ofMedicolegalreportSummary of reportSuch as torn ligament left leg, painful to walkfor 6 months/unable to resume work for 3monthsPrepared and relevant as at November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on3239 6546 to ensure that its contents are current.Page 2 of 8

Centre)? Please give details of the Police Officer,doctor or agency (and a description of the agency).NB Lack of early reporting may be a ground forrefusing a claim. If there has been delay pleaseexplain the reason.Police ReportIt is not necessary for you to obtain a Police Report. However, if already obtained by you, attachcopies of statements made to police (if any) and/or Criminal Offence Report (if any).Date incident reported to Police. (NB: The lack of earlycomplaint to police may cause the application to berefused)Police Station reported to:Name of Investigating Police Officer(s):CURRENT location of Investigating Police Officer(s)[lack of this information may delay your application]:C.R.I.S.P. number: (this is supplied by police whenmatter is reported & will expedite the police report)SECTION G FURTHER PARTICULARSWas victim intoxicated?Did the victim contribute to injuries (eg falling down stairswhile intoxicated)Did victim contribute in any way to the events which led tothe injury (eg provoking an argument)Money received from other sources1. Have any Moneys been received from:a) A civil claim in the Courts or otherwise forpersonal injuries;eg. any negligence action.NB: if such action can be brought this applicationwill not be considered until the Personal InjuriesAction is finalised.Prepared and relevant as at November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on3239 6546 to ensure that its contents are current.Page 4 of 8

) Any law relating to Workers' Compensation;NB: If the Offence(s) occurred at work (or on theway to or from work) this application forcompensation will not be considered until Workers'Compensation has been finalised.c) An insurance claim;d) Any other source?2. If moneys have not yet been received can moneysbe recovered from any of the above sources?3. Have all steps been taken to recover moneys fromall of the above sources (give details of stepstaken)Details of any special or extraordinary circumstances you believe should be consideredRelationship of offender/applicant (including living in samehousehold)Is there any possibility that offender may benefit from theclaim (such as by living in same household). If so pleaseexplain how it will be ensured offender does not getbenefit of compensation.Are there any other matters you believe should be takeninto account in assessing this applicationSECTION H TO BE COMPLETED ONLY IF INJURED HELPING A POLICE OFFICERWas the victim helping a Police Officer?Name & number of the Police OfficerWas the Police Officer:i) Trying to arrest someone (give details);ii) Preventing or attempting to prevent an offence orsuspected offence (give details)Prepared and relevant as at November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on3239 6546 to ensure that its contents are current.Page 5 of 8

TO BE COMPLETED IF IDENTITY OF OFFENDER UNKNOWN AT TIME OF APPLICATIONI………………………………………agree that if at any future time I become aware of the identity orwhereabouts of the person responsible for my injuries, I will notify the Director-General, Department ofJustice and Attorney-General immediately.Signed(please print full name)Witnessed(please print full name)Dated the …………….day of ………………….20 .NB That section 663E of the Criminal Code and section 38 of the Criminal Offence Victims Act 1995 provide thatshould you receive any payment from the offender, or become entitled, whether by an order of a court or by acompromise of action, to receive an amount of money in respect of the injury in relation to which this approval hasbeen given, that amount is charged by way of a first charge in favour of the Attorney-General and Minister for Justiceto the extent of the amount of the payment received by your client from the Queensland Government.TO BE COMPLETED BY APPLICANTOATHS ACT 1867 (as amended)I, make this solemn declaration by virtue of the Oaths Act 1867(as amended) that, to the best of my knowledge and belief, the information supplied on this application forCriminal Injury Compensation is true and correct in every particular. I acknowledge and make thisdeclaration in the belief that a person making a false declaration is liable to the penalties of perjury.Signature (applicant)Taken and Declared before me at this day of________________ 20 .WitnessJustice of the Peace for Queensland/SolicitorIf not in Queensland at the time of completing this form please ensure that this statutory declaration isamended and completed according to the law of the place where it is swornPrepared and relevant as at November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on3239 6546 to ensure that its contents are current.Page 6 of 8

INFORMATION SHEETCRIMINAL INJURY COMPENSATION (CIC)FOR APPLICANTS WITHOUT COURT ORDERSPrivacy StatementThe information collected for your application is collected to enable the Department of Justice & Attorney-General to process your application for an ex gratia payment of criminal injury compensation. This informationmay be disclosed to those persons necessary to verify your claim (eg. investigating Police Officers; the Officeof the Director of Public Prosecutions; Corrective Services) and to any person with a lawful entitlement toobtain the information. This information will be disclosed to departmental officers involved in processing yourclaim and to the Governor-in-Council. Failure to supply the requested information may mean that theDepartment is unable to process your claim.The following material MUST accompany all applications: Completed application form Copy of client’s authority (see over for suggested wording) Copy/ies of Medico-legal report(s) supporting ALL injuries for which compensation is sought (i.e. no awardof compensation will be made for mental/nervous shock not supported by a psychiatrist’s orpsychologist’s report).[NB – if the applicant is seeking compensation for Adverse Impacts of a Sexual Offence pursuant toRegulation 1A Criminal Offence Victims Regulation 1995, where relevant, the psychological /psychiatric report should clearly distinguish between an injury falling within the diagnosis of mental ornervous shock, and an injury falling outside that diagnosis but compensable as an adverse impact. Ifyou have any queries about this aspect of the application, please contact the Criminal InjuryCompensation Unit (07) 3239 6546.] Copy of the applicant’s statement(s) to police(This is available FREE to applicants on request to the investigating police officer)The Governor in Council DOES NOT require any of the following material: Copies of hospital inpatient records Copies of documents generated by Police Investigations Copies of witness statements (other than of an applicant’s statement)Information for ApplicantsThe department receives as many as 100 applications for criminal injury compensation per month.Although everything is done to expedite processing, it may take between 6-9 months for an applicationto be finalised because information must be obtained from other agencies (eg. the Queensland PoliceService).Ex gratia payments of criminal injury compensation may be available to a person who has suffered aninjury because of the commission of an indictable offence against them. Please note that there is nocompensation available under this scheme for loss of property, for injury or for loss suffered as a resultof the commission of an indictable offence unrelated to the person of the applicant.As a matter of policy legal costs are not included in ex gratia payments.Prepared and relevant as at November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on3239 6546 to ensure that its contents are current.Page 7 of 8

All applicants criminally injured in the course of their employment must provide a letter from WorkCoverthat states what amounts, if any, the applicant has received or can receive from WorkCover as a resultof the injuries sustained.Where an applicant injured as a result of a criminal act has an entitlement to pursue a civil action inrelation to these injuries, the applicant or their legal advisers are required to provide an advice on theapplicant’s prospects of success in that action. Either a solicitor or a barrister may prepare the advicewhich must fully canvass the relevant legal issues.As criminal injury compensation is an ex gratia payment payable from the public purse, where anapplicant is involved in other proceedings relevant to the consideration of their application, processingof their application may be suspended until the other matter/s are finalised.An ex gratia payment of criminal injury compensation is made from the public purse. In making anydetermination, it may be possible that the payment of public monies where they could be used toacquire illegal drugs would be seen as contrary to public policy. Where there is evidence to indicatethat an applicant has used or is using an illegal drug within seven years of the date of receipt of theapplication, the applicant will be requested to provide a pathology test result to indicate whether theapplicant is currently using illegal drugs. Where an applicant chooses not to provide a pathology testresult or tests positive to the presence of illegal drugs, the Governor in Council may decide that any exgratia payment approved be forwarded to the Public Trustee to be held in trust for the applicant.An ex gratia payment of criminal injury compensation is made from the public purse. In making anydetermination, it may be possible that the payment of public monies where they could be of benefit tothe offender would be seen as contrary to public policy. Where there is evidence to show that anapplicant continues to reside with the offender the Governor in Council may decide that any ex gratiapayment approved be forwarded to the Public Trustee to be held in trust for the applicant.If at any stage you have any questions relating to your application, you should contact the Departmentthrough your legal advisers. This will ensure that the issue has not already been dealt with by yoursolicitors and may save you legal costs as the department’s practice is to contact an applicant’ssolicitor to discuss the issues raised by the applicant.Under the Judicial Review Act 1991 applicants are entitled to request a Statement of Reasons within28 days of receiving notification of the Governor in Council’s decision. Applicants can also makeapplication to the Supreme Court to seek a review of the decision.Applicants may also make a written complaint to the Ombudsman in accordance with the provisions ofthe Parliamentary Commissioner Act 1974 in respect of any recommendation made to the Minister.The Government has provided Legal Aid Queensland (LAQ) with a grant to enable LAQ to assistvictims of crime obtain criminal injury compensation. No means test is applied by LAQ to thesevictims and legal fees are capped at $4,400. LAQ can be contacted on 1300 651 188.The Government provides funding to victims of crime groups to offer a number of counselling sessionsto victims of crime. If you are in need of support or counselling the Victims of Crime Association can becontacted on 3252 2630.Client’s AuthorityThe client’s authority must be worded in a similar format to the following:“I [Name of Applicant] am represented by [Name of Solicitors] in relation to my criminal injury compensationapplication.I have discussed the particulars of my application, including the costs associated, and I hereby authorise themto act on my behalf in this matter. [Name of Solicitors] are further authorised to receive all material on mybehalf with respect to my criminal injury compensation application”.Prepared and relevant as at November 2003. If this form is over 12 months old, kindly contact the Criminal Injury Compensation Unit on3239 6546 to ensure that its contents are current.Page 8 of 8