Rule 9 Contents of Application

The application for a claim must contain the following:

(a) Information or facts sufficient to establish eligibility;

(b) Whether the claim is for injury, death benefits, or other compensable economic losses, or an emergency award;

(c) Whether the claimant is a victim, a secondary victim, or a person (not a provider of services) acting on behalf of the victim or secondary victim;

(d) A description of the injury or death, date of crime, and any known information concerning the offender;

(e) The name, address, phone number, and birth date of the victim or secondary victim and the claimant (if different from the victim or secondary victim);

(f) The name, address, and birth date of any dependent included in the claim;

(g) Sufficient information and documentation to support each claim of economic loss;

(h) Information regarding any restitution, insurance, or other collateral source of benefits or compensation related to a claim;

(i) A declaration of subrogation and suit notification signed by the claimant;

(j) For a claimant seeking compensation for medical expenses, any necessary authorization permitting:

(1) release of all medical bills relating to the victim’s or secondary victim’s injuries for which compensation is sought; and

(2) the medical provider to complete the certification required by Rule 13;

(k) Any other necessary authorization for release of non-medical information related to a claim;

(l) An affirmation signed by the claimant; and

(m) Any other information that the Program reasonably may require.