Claim for compensation after a personal injury

Transcription

1 Criminal Injuries Compensation Authority Tay House 300 Bath Street Glasgow G2 4LN Phone: Ecophone text: Fax: Website: For office use only Reference number: Criminal Injuries Compensation Scheme Made by the Secretary of State under the Criminal Injuries Compensation Act 1995 Claim for compensation after a personal injury This form is not a guide to the Criminal Injuries Compensation Scheme. You can get a guide from us at the address above. Fill in this form if you want to claim compensation for a personal injury (or injuries) received as a result of a single incident or abuse over a period of time. If you want to claim compensation for injuries arising from unrelated incidents or abuse, you must fill in a separate claim form for each incident. If you are filling this form in for someone else, please remember to fill it in as if you are the injured person. If the person who was injured has died, please do not use this form. In this case, ask us for a Fatal Application form. Fill in this form in block capitals and by ticking any boxes that apply. When we receive your claim, we will send you a reference number which you should quote whenever you contact us. We will store and process the information you provide in line with the Data Protection Act Under that Act you can ask to see all the information we have about you. If any of the information you give in this form changes, you must immediately give us written details of the change. We aim to treat you politely and with care. In return, we expect you to be polite to our staff. For instance, if you abuse, threaten or swear at our staff on the phone, we will end the call. 1 Details of the injured person a b c d e Title (Mr, Mrs, Miss and so on): First names: Last name: Any other last name you have used (for example, your maiden name): Address and postcode: f Date of birth: Town of birth: g Are you: male? female? h Are you: married? single? widowed? divorced? separated? living with a partner? i j k Daytime phone number (not a mobile number): National Insurance number: Occupation at the time of the injury: TS14 (07/05) 1

2 2 Details of the person filling in this form Fill in this part only if you are applying for compensation on behalf of an injured person who is under 18 or incapable of handling their own affairs. If the injured person is not capable of handling their own affairs, you must be properly authorised to act for that person. If the injured person is under 18, you should normally be their parent or guardian, otherwise this application could be delayed. Also, we need the original birth certificate of anyone under 18 (it must be the full, original birth certificate if their last name is different from yours). Please send it to us using recorded delivery post. a Your title (Mr, Mrs, Miss and so on): b First names: c Last name: d Any other last name you have used (for example, your maiden name): e Address and postcode: f Your daytime phone number (not a mobile number): g Relationship to the injured person: h Is the injured person: incapable of handling their own affairs? Go to part 3. under 18? If so: Is there a care, supervision, residence or other local authority order over the person? Go to part 3. If so: Name and address of local authority: Name of social worker: Case reference number (if known): 2

3 3 Details of any representative helping with this claim If you want, you can use the services of a representative (such as a Victim Support Scheme, a solicitor, a trade union or Citizens Advice). We are not responsible for your legal costs. Also we cannot pay compensation to children under 18 to anyone other than their parent or guardian. a Is a representative helping you with Go to part 4. this claim? If so, give the representative s details below. b Representative s full name: c Address and postcode: d DX number (if appropriate): e Phone number: f Reference number we should quote: (This should be in any letter you have received from your representative.) g Do you want us to deal directly with the representative? 3

4 4 Details of the incident a Is the injury a result of: a single incident? Date: Time: am pm b If the incident, or the last instance of abuse, happened more than two years ago, why have you not applied before now? abuse over a period of time? From: To: : c Your address and postcode at the time of the incident or abuse (if different from your present address): d Full address of where the incident or abuse happened: (Please say if you were inside or outside.) e What happened? (Continue on a separate sheet if necessary.) 4

5 4 Details of the incident (continued) f Who injured you? (Give their full name if you know it.) g Were you and the person who injured you living in the same household, as members of the same family, at the time of the incident or abuse? If so: are you and the person who injured you still living in the same household as members of the same family? h Did anyone see the incident or abuse, receive an injury from the incident, give information about the incident to the police or receive an injury Go to part 5. from the same person? Give their names and addresses below. 5

6 5 Details of the report to the police a Were the police told about the Go to 5b and then part 6. incident or abuse? Go to 5c. b Why wasn t the incident or abuse reported to the police? w go to part 6. c Did you, or someone acting for you, make a formal report? d Who told the police about the You Go to 5e. incident or abuse? Someone else Who? Why didn t you report the matter yourself? e When were the police first told about the incident or abuse? Date: Time: am pm f If the police were not told about the incident or abuse immediately, please explain why. : g Name and number of the officer the incident or abuse was reported to (if known): h Address of the police station the incident or abuse was reported to: i What is the crime reference number? (Our investigations may be delayed if we do not have this number.) Please send us any letter the police have given you. If you cannot provide a crime reference number, please explain why. j Did you give the police a written statement? k Was the person who injured you convicted for the incident or abuse? Don t know te: When we are considering your claim, we will contact the police for information about the incident. We may reduce or withhold compensation if, for example, there was a delay in reporting the matter, you withdraw your complaint at any stage, or you refuse to co-operate with prosecuting the offender. 6

7 6 Details of the report to any other authority It may have been appropriate for you to report the incident or abuse to another authority. (For example, if you are a nurse, teacher or prison officer who was assaulted on duty or if a child was assaulted at school.) a Was the incident or abuse reported to Go to part 7. any authority other than the police? Answer all the questions in this part. b Did you report the incident or abuse yourself? Why not? If so: who did you report the incident or abuse to? Name: Address: c When was the incident or abuse reported? Date: Time: am pm d If the matter was not reported immediately, explain why. : e Did you make a written statement? 7 Description of injuries a Describe the physical and mental injuries you received. (You do not need to use medical terms or send photographs unless we ask for them.) b Have you fully recovered from your injuries? Go to 7c. Go to 7e. c What are your current symptoms? We may write to you for more information. d Are you still receiving treatment for your injuries? e Have the injuries left any permanent scarring or deformity? te: We will get medical reports from your doctor and, if we need to, the hospital which treated your injury. 7

8 8 Details of treatment a Did you go to hospital? Go to 8b. If so: name and address of the first hospital you went to: consultant s or department s name (if known): hospital reference number: how long were you in this hospital? From: To: dates of outpatient visits to this hospital as a result of the incident or abuse: name and address of any other hospital you went to: consultant s or department s name (if known): hospital reference number: how long were you in this hospital? From: To: dates of outpatient visits to this hospital as a result of the incident or abuse: 8

9 8 Details of treatment (continued) b Did you see a doctor, other than at Go to 8c. a hospital, for medical, psychiatric If so, give their name and address below: or psychological treatment? dates of visits to this doctor as a result of the incident or abuse: c Name, initials and address of your GP: Phone number: d Did you need dental treatment? Go to part 9. If so: name and address of dentist or dental hospital: dates of visits to this dentist as a result of the incident or abuse: 9

10 9 Loss of earnings and special expenses If your injury prevents you from earning for longer than 28 full weeks, you may be able to get compensation for loss of earnings. However, you cannot get compensation for earnings lost in the first 28 full weeks. You may be able to get extra compensation to cover special expenses if your injury prevents you from working, going to school or, if you are retired, following your normal lifestyle, for more than 28 full weeks. Special expenses can include the following. The cost of repairing or replacing physical aids you relied on (such as glasses and false teeth) and which were lost or damaged as a direct result of the incident or abuse. Costs (not including loss of earnings) associated with getting NHS treatment for the injury. Examples of costs include prescription charges, dental and optical charges or fares to hospital if the costs are not paid in full by the NHS or the Department for Work and Pensions. The cost of private medical treatment for the injury if, in the circumstances, we think the private treatment is appropriate and its costs are reasonable. The reasonable cost of any special equipment you need, or adaptations that need to be made to your home as a result of your injury. The reasonable cost of any care you need, whether in a residential care home or at your own home, which is not available free of charge from the NHS, your local authority or any other agency, as long as we think the care and its expenses are necessary as a direct result of your injury. a Have you been, or do you expect Go to part 10. to be, unable to work, study or Answer the rest of the questions in this part. follow your normal lifestyle for more than 28 full weeks as a result of the injury? b Have you gone back to work? c Have you lost, or do you expect to lose, earnings or the ability to earn for more than 28 full weeks as a result of the injury? d Have you had to pay any special expenses? When did you go back? If you have answered to any of the questions in this part, we may send you more information and a form for claiming loss of earnings and special expenses. 10

11 10 Payments and compensation from other sources You must tell us about any claim you have made, or any payments you receive, as a result of your injury. We may take the amount of any payment off the compensation we pay you. a Have you claimed compensation Go to 10b. for your injury from another person Give details below. or organisation (such as the Motor Insurers Bureau)? Name and address of the person or organisation: Date of application: Reference number: b Do you intend to apply to any other Go to 10c. person or organisation (other than If so: a court) for compensation for your injury? Name and address of the person or organisation: c As a result of your injury, have you received, or do you hope to receive: compensation or damages under any court order? compensation or damages from any other source? Give details below (including your solicitor s name, address and postcode). Give details below (including your solicitor s name, address and postcode). Amount received or expected: Claim reference number (if known): 11

12 11 Previous applications a Have you claimed criminal injuries Go to part 12. compensation before? Give details below. Date of incident or abuse: Date of claim: Claim reference number: Date of incident or abuse: Date of claim: Claim reference number: 12 Your remarks The information you have given on this form should be enough for us to consider your claim. If you want to add anything that you think will help your claim, please give details in the space below. (Continue on a separate sheet if necessary.) 12

13 13 Authorisation Please read this part carefully before you sign below. Your signature authorises us to investigate your claim and get reports from relevant authorities. I have read and agree with the following statements: The information I have given in this form is true. If I deliberately provide false information on this form, you may refuse my application under paragraph 13 of the Scheme. (Examples of false information include deliberately exaggerating injuries or, if I am claiming loss of earnings, giving deliberately false or incomplete information about my earnings or benefits.) You may also refuse my application if I send in two forms for the same incident and do not explain that one is a copy. I understand that you may contact the police, Department for Work and Pensions or other organisation if you consider that any information provided to support this application is fraudulent. I will give you and the Criminal Injuries Compensation Appeals Panel (the Panel), if appropriate, written details if any of the information I have provided in this form changes. I will tell you and the Panel, if appropriate, if I claim compensation or damages for the injury set out in this form from any other person or organisation. I will tell you and the Panel, if appropriate, if I receive damages or compensation, from any other source, for the injury set out in this form. I will give you and the Panel, if appropriate, all the reasonable help you need and let you see all medical reports about my injury. The following organisations can supply any information you or the Panel, if appropriate, need for this claim. The police (including police doctors, surgeons, pathologists and Interpol) Medical authorities My employers (past and present) Relevant government agencies The Inland Revenue The Motor Insurers Bureau Relevant local authorities Any other person or organisation with information relevant to this application You and the Panel, if appropriate, may tell the people and organisations listed above that I have made this application, and tell them your decision. You can ask any court that awarded me compensation to hold that compensation until you have reached a final decision about my claim. 14 Signature If the injured person is aged 14 or over, they must sign at (a) below. a Injured person s signature: Name (please print): Date: If you are filling in this form for someone who is under 18 or incapable of handling their own affairs, you must sign at (b) below. b Parent s, guardian s or authorised person s signature Name (please print): Date: 13

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15 For office use only Reference number: Ethnic monitoring form We aim to provide a fair service that treats everyone equally. To make sure we are doing this, we gather information about the ethnic origin of people making claims. We keep this questionnaire separate from the claim details and we destroy the questionnaire once we have monitored our performance. Please help us by ticking the box below that best describes your ethnic origin. (You do not have to fill in this section, and your response, or lack of response, will not affect your claim.) White British Irish Other white background Mixed White and black Caribbean White and black African White and Asian Other mixed background Asian British Indian Pakistani Bangladeshi Other Asian background Black British Caribbean African Other black background Chinese Other ethnic group Thank you for your help. 15

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