APPLICATION FOR COMPENSATION 1 SECTION A ... - Vintec

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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)<strong>SECTION</strong> 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 application<strong>SECTION</strong> 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
Page 1 and 2: RETURN FORMS TO:Your Legal Represen
Page 6 and 7: TO BE COMPLETED IF IDENTITY OF OFFE
Page 8: All applicants criminally injured i

APPLICATION FOR COMPENSATION 1 SECTION A ... - Vintec

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