Application for a personal injury award following a period of abuse (physical and/or sexual) (EU use only)

Transcription

1 Criminal Injuries Compensation Authority Alexander Bain House Atlantic Quay 15 York Street Glasgow G2 8JQ Telephone Telephone (from outside the UK): +44(0) For office use only Reference Number Application for a personal injury award following a period of abuse (physical and/or sexual) (EU use only) How to fill in this form We need this information to assess eligibility for an award and may send the form back to you if there is information missing. This could delay the application process. If you are having difficulty completing this form please call one of our advisors on the above telephone numbers. Our advisors are available to take calls from 8.30am to 5pm (UK time) on Monday to Friday, except Wednesday when they are available from 10am to 5pm (UK time). Fill in the form in BLOCK CAPITALS and check boxes that apply. Use section 11 to provide any additional information you want and continue on extra sheets if necessary. If you are applying on behalf of someone else, answer the questions as though you were the applicant. You will also need to complete section 2 of the form. You can get more information from the European Commission Judicial Atlas. We will store and process the information you provide in line with the Data Protection Act Under the Act you can ask to see all the information we have about you. Assisting Authority statement If you are an EU Assisting Authority please complete this section. No-one else need complete this section. I confirm I have supported this claimant in completing their application Assisting Authority contact name: Assisting Authority address:

2 Eligibility statements Please check yes or no for each of the following questions. The incident a) Were you injured on or after 1 August 1964? b) Were you present and injured in an incident in England, Scotland or Wales? c) Did you suffer a physical or psychological injury as a result of a violent crime, or were you present and injured when someone closely related to you was the victim of a violent crime? d) Is the injury for which you are claiming included in the tariff of injuries at Annex E of the Scheme? e) Was the incident reported to the police? If you answered no to any of these questions you might not be able to apply for an award. Please call us on the telephone numbers at the top of this form for further clarification. Otherwise, please continue. Nationality and residency On the date of the incident giving rise to the application were you either: a) a British citizen or a close relative of a British citizen 1 b) a national of a member state of the European Union or European Economic Area or a family member of such a national with a right to be in the United Kingdom (UK) by virtue of your relationship to that person? c) a member of HM Armed Forces or an accompanying close relative? d) ordinarily resident in the UK? On the date of the application were you either: e) referred to a competent authority as a potential victim of trafficking in human persons? f) applying for asylum under Immigration Rules made under section 3(2) of the Immigration Act 1971? 1 Paragraph 12 of the Scheme defines close relative for this purpose

3 Please note that when we get your claim we will tell you what information we need from you and we will verify this as needed. If you do not supply information that we ask for we may refuse an award. Section 1: Your details a) Title (Miss, Mr, Mrs, Ms, etc): b) Last name: c) First name: d) Any other name(s) you have used: e) Date of birth: f) Gender: Male Female Transgender g) Address and post/zip code: h) Contact telephone number: i) address: We will send essential information by post. We may also contact you by telephone where necessary. Please tell us when you would prefer us to call you. We can make calls from 8.30am to 5pm (UK time) on Monday to Friday, except on a Wednesday when we are available from 10am to 5pm (UK time). OR If you would prefer that we deal with your representative (details contained in Section 2) rather than contacting me directly, please check this box j) Are you acting as a representative/assisting authority? (If yes, please complete the representative/assisting authority details in Section 2; if no, please proceed to question (k) k) Are you applying on behalf of someone who is under the age of 18? (If yes, please complete the representative/assisting authority details in Section 2; if no, please proceed to question (l) l) Are you applying on behalf of an adult who is legally incapable of managing their own affairs? (If yes, please complete the representative/assisting authority details in Section 2; if no, please proceed to the details of abuse questions in Section 3

4 Section 2: Representative/assisting authority details You only need to complete this section if you are applying on behalf of someone else. Please check the relevant box: I am applying on behalf of someone for whom I have parental responsibility If yes, complete Section 2(a) and (b) I am applying on behalf of someone over 18 who is legally incapable of managing their own affairs If yes, complete Section 2(a) and (c) I am acting as the applicant s representative/assisting authority If yes complete Section 2 (a) and (d) Section 2 (a) Your details Title (Miss, Mr, Mrs Ms, etc): Last name: First name: Address and post/zip code: Contact telephone number: address: Relationship to the applicant (for example, parent, guardian, social worker, legal representative, assisting authority): Should we correspond with you directly?

5 Section 2 (b) Persons with parental responsibilities for the applicant Do you share parental responsibility with another parent or guardian? If yes, please give that person s name: Is there a care, supervision, residence, local authority, or court order over the child? If yes, give the name and address of the authority responsible for the order and provide a copy of the documentation. Section 2 (c) Persons acting on behalf of someone over 18 years of age who is legally incapable of managing their own affairs Has the person been found to be legally incapable of managing their own affairs under the appropriate legislation? (For example, in England and Wales, adults with incapacity are protected under the Mental Capacity Act 2005 and in Scotland, the Adults with Incapacity (Scotland) Act These legislative acts allow the court to appoint someone to manage the incapacitated adults affair). Do you have legal responsibility for this person? (i.e. has a court appointed you to act on their behalf?) If yes please provide evidence of this. Section 2(d) Persons otherwise acting as the applicant s representative Reference number we should quote in correspondence: Please confirm that you have explained to the applicant that they are responsible for paying any fee you may charge:

6 Section 3: Details of the abuse We appreciate that recounting the period of abuse may be difficult. However, the information we ask for is essential in order for us to assess your claim. a) Please tell us when the abuse began and when it ended: Start End b) Full address(es) where the incidents took place: c) Please give very brief details of the incidents in the space below d) Were you and the person who injured you living together as members of the same family at the time of the incident? Yes No e) If yes, are you and the person who injured you still living together as members of the same family? Yes No

7 Section 4: Reporting the abuse to the police a) When was the abuse reported? b) Was the abuse reported to the police? If the incident was reported to another authority but not to the police please go straight to question (o) c) Which police force was the abuse reported to? d) Address of the police station where the abuse was reported: e) Name and identification number of the police officer the abuse was reported to f) The police will have a reference number they use to identify this abuse. Please get it from them and provide the detail here g) Did you make a formal statement to the police? h) Has the case gone to court? i) Is the case going to court? j) Date of court case k) Has your assailant been identified? l) Who caused your injuries? m) If there was a delay in reporting the abuse, please provide the reason for this, so we can take the explanation into account: n) Who reported the abuse? o) If you didn t report the abuse to the police, please provide the name of the authority you reported it to:

8 Section 5: The injuries a) What injuries did you receive? b) Have you attended a hospital or your GP for treatment for your injuries? c) Are you still receiving treatment? d) If yes, what are your current symptoms? Section 6: Medical details a) Doctor/General Practitioner (GP)/Surgery name: b) Doctor/General Practitioner/Surgery Address: c) Date of first visit to Doctor/GP/Surgery: d) Did you go to Hospital/Accident & Emergency (A&E)? e) Hospital/A&E address: f) Date attended Hospital/A&E: g) Hospital/patient reference number: h) Have you attended any other hospitals for treatment? i) If yes please provide the name and address of other hospitals visited:

9 j) Dates attended: k) Hospital/patient reference number: l) Consultant/practitioner s name: m) Department: n) If you sustained facial/dental injury, did you visit a dentist? o) Dentist s name: p) Dentist s address: q) Date of first visit: r) Did you visit any other treatment providers (e.g. physiotherapist)? s) If yes, please provide details of other treatment providers: t) Are you due to receive any further treatment? If yes, please go to question u ; if no, please go to question x u) Who will treat you? v) When will this treatment begin? w) Address where you will have further treatment: x) Have any of your injuries resulted in scarring?

10 Section 7: Loss of earnings and special expenses a) Do you have very limited capacity or no capacity for paid work as a direct result of your injuries? b) Have you lost earnings or earning capacity or been incapacitated to a similar extent for more than 28 weeks? c) If you were off work, when did you go back? Section 8: Previous applications a) Have you claimed criminal injuries compensation before? b) If yes, please give us your previous CICA reference number(s) (for example, X/02/ CW-89) c) Your name at time of incident: d) Date of application: e) Address at time of incident: Section 9: Payments or compensation from other sources You must tell us about any other claims you make or have made to other organisations and also about any payments you receive or have received as a result of this incident. Please give the name and full address of the person or organisation from whom you expect to receive payment, the date on which the claim started, and the amount of compensation you have received or hope to receive. a) Name of person or organisation: b) Address and post/zip code: c) Date claim started: d) Amount you have received or expect to receive:

11 Section 10: Criminal convictions in the UK or abroad We must consider an applicant s unspent criminal convictions and conduct checks on these convictions. To help us deal with your case, if you have criminal convictions, you must provide details below, starting with the most recent. If you were convicted abroad, please tell us the country. Do you have any criminal convictions, including simple cautions or reprimands, in the UK or abroad? Offence 1 Offence 2 Sentence: Sentence: Date of sentence: Date of sentence: Offence: Offence: Country: Country: Offence 3 Offence 4 Sentence: Sentence: Date of sentence: Date of sentence: Offence: Offence: Country: Country: If you have any further convictions please list them below using the same format as above (sentence; date of sentence; offence; country): Section 11: Additional information Please tell us anything else that you think we need to know. Please continue on a separate sheet if necessary. Question number Additional information

12 Consent and signature form Please sign the consent form and return it to us at the address on the front page or by to Please read this part carefully before you sign it. Your signature authorises the Criminal Injuries Compensation Authority ( the Authority ) to investigate your claim and get reports from the relevant people and organisations. If you have appointed a representative your signature also authorises us to correspond with them. Please note that awards to minors will normally be retained. I have read and agree with the following statements: 1. The information I have given the Criminal Injuries Compensation Authority ( the Authority is true. I understand that if I knowingly give information that is incorrect, I may be liable to prosecution or other action. 2. The Authority has my permission to carry out a check on my unspent convictions (and in the case of fatal applications, the unspent convictions of the deceased). 3. I agree to notify the Authority or, if appropriate the First Tier Tribunal-Criminal Injuries Compensation (FTT-CIC) of any changes to the information I have provided or will provide. 4. I consent to the Authority providing HM Revenue & Customs (HMRC) with information I have provided in this form and to HRMC providing the Authority will all details of my taxable earned income (including its source) and my National Insurance contributions to date. Only the minimum information needed by the Authority to assess my information will be shared. 5. I give my consent for the Authority to contact any of the organisations listed below and obtain information from them in order to process my claim or to verify any of the information I have provided. The Authority may also tell the people and organisations listed below that I have made this application and tell them of the decision in my case where appropriate: a) Police authorities in any country I may have lived as an adult; b) Association of Chief Police Officers Criminal Records Office (ACPO/ACRO); c) Medical authorities and practitioners (including police doctors and surgeons) with information relevant to my case; d) Department for Work and Pensions; e) HM Revenue & Customs; f) Any other person or organisation with information relevant to this application; g) The representative named by me (if any). If the injured person is 12 years or older they must sign this form at a) below. If you are filling in this form for someone under 18 or for someone who, even with assistance, lacks the capacity to understand it or make a decision on it, you should sign at b) below. a) Sign b) Sign Name in block capitals: Name in block capitals:

13 Date: Date: