CICF Claim Application

Please type or print with ink, and answer all questions on the form. If it does not apply, mark N/A in that space.
Attach all bills, receipts, insurance or benefit statements with application and send copies of additional bills and benefit statements for continuing treatment to above address. All submitted bills must be itemized statements of the services rendered.
If the victim is a minor or mentally incompetent, the claimant (person filing for victim) must be an adult who is responsible for the victim's welfare.
If the claimant/victim is not covered by insurance and is treated at a hospital, victim must contact the Department of Social Services within 30 days after leaving the hospital to receive help with payment of hospital bill.
If filing for mental health counseling for "survivors" only, complete entire application and attach a copy of the appropriate marriage or birth certificate.
Submit original Claim Form with all attachments.

The crime was committed in Virginia or a state where Virginia residents are not eligible or as a result of a terrorist act.
The crime was reported to a law-enforcement agency within 120 hours (unless good cause can be shown for not doing so).
The victim suffered personal physical injury or death as a result of criminal acts.
The victim suffered emotional injury as a result of a felony.
The victim cooperated with law-enforcement agencies and the courts.
The victim was not engaged in any illegal activity at the time of the crime.
The victim did not provoke, incite or willingly take part in the incident.
The claim was filed within one (1) year from the date of the crime (unless good cause can be shown for the late filing).
Victims of child sexual assault may file 10 years from their 18th birthday (unless good cause can be shown for the late filing).
The claimant is the spouse, parent, grandparent, adult child, sibling or legal dependent of a deceased victim who paid or is liable to pay the funeral bill of a victim.
The claimant is a surviving family member who suffered emotional injury due to the homicide of a parent, spouse, sibling, child or grandchild.
The claim has a minimum value of $100.

Pain, suffering or property loss
(Prosthetic devices are not considered property)
Injuries resulting from vehicular accidents
(Except victims of Drunk Drivers)
Attorney's fees
Losses covered by insurance, public funds or estates

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