Expenses Eligible For Reimbursement

The TOTAL MAXIMUM award is $15,000.00

Expenses considered by the Fund must be directly related to the crime

PLEASE NOTE: CICF will consider payment for providers whom your insurance company may refer to as out of network.

Benefits	Tips	Items needed to make a payment	Explanation of forms
Medical or Dental Expenses	Anything not covered by insurance, Social Security, Medicare, Medicaid, workers compensation, disability programs or other coverage the victim may have had at the time of the crime. CICF will pay co-pays!	• Completed application • Police report • Medical records • Itemized medical bills • Copies of all insurance cards, or Explanation of Benefits from all insurance coverage carriers	Itemized Medical bills and medical records: RECORDS: this would show how your injuries relate to the crime and/or crime date. ITEMIZED STATEMENT: this is NOT a bill with only balance information…this should be a copy of all procedures and the cost break down for each.
Mental Health Counseling	The only cap is for survivors of homicide victims: $2,500.00. Counseling must be provided by a licensed mental health professional. Anything not covered by insurance, or other coverage the victim may have had at the time of the crime. CICF will pay co-pays!!	• Completed application • Police report • confidential medical information and records, including office notes for each counseling session, generated by victim’s therapist to establish that treatment is directly related to the crime and is not focused on pre- or post-existing conditions irrelevant to crime trauma • diagnostic information • treatment plan with measurable goals and estimated date of completion • quarterly treatment plan updates (if applicable) • itemized statement of victim’s charges • Copies of all insurance cards, or Explanation of Benefits from all insurance coverage carriers	Itemized Medical bills and medical records: RECORDS: this would show how your injuries relate to the crime and/or crime date. ITEMIZED STATEMENT: this is NOT a bill with only balance information…this should be a copy of all procedures and the cost break down for each.
Lost Wages	• wage loss based on 2/3 of the wages up to a maximum of $600 per week (Vacation and/or sick leave time can not be reimbursed by the Fund)	• Completed application • Police report • Employer Report form completed by employer • Disability statement completed by physician	Employer Report Form: CICF will mail your employer (with the information you provide us on your application) the Employer Report form for them to complete and return to CICF. This form will tell CICF your wage amount and confirm the days missed due to the injury. Disability Statement: CICF will mail your physician a Disability Statement Form for them to return to CICF. This form will tell CICF that your injury relates to the crime and the amount of time your doctor has suggested you miss work due to your injury.
Lost Support	To Eligible Family members based on 2/3 of the wages up to a maximum of $600 per week	• Completed application • Police Report • Copies of protective order • Copy of W-2s, or current pay check stub or current employment verification
Moving	Up to $1,000.00 Moving expenses will be paid on a reimbursement basis only.	• Completed application • Police Report • Please send in copies of receipts for moving expenses	Please send in copies of receipts for moving expenses rental of truck for moving the victim's/survivor’s personal belongings; reasonable expense for professional labor to move the victim's/survivor’s personal belongings; cost of utility hookups, but not the utility deposit; first month’s rent and the security deposit, if a lease is broken)
Funeral	Up to $5,000.00	• Completed application • Police Report • A copy of the death certificate • A copy of the funeral contract • Information on any life insurance policy on the victim
Mileage	For medical services for victim or for parent of child victim CICF can not pay for mileage to and from court proceedings, please request this mileage reimbursement from your local Victim Witness Office or Commonwealth’s Attorney’s Office	• Completed application • Police Report
Crime Scene Clean Up	Professional clean up of bodily fluids, when the crime occurs in the victim’s residence. Homeowners’ insurance is considered a collateral resource for this expense.	• Completed application • Police Report • Receipts/bills from purchases of cleaning supplies or from professional cleaning companies are required in order to pay this expense.
Other Reasonable & Necessary	• Such as changing locks, prescriptions, eyeglasses, or bedding or clothing if it is taken as evidence.	• Completed application • Police Report-some reference in the police report of the items in question • Receipts of