Forms
Name of Form |
Acrobat |
MS Word |
|---|---|---|
| CICF Application | PDF ( 2,341 kb) | |
| CICF Authorization page | PDF ( 2,341 kb) | |
| Police Report | PDF (551 kb) | |
| Physician Report | PDF (623 kb) | |
| Dental Report | PDF (220 kb) | |
| Employer Report | PDF (326 kb) | |
| Disability Report | PDF (26 kb) | Doc (27 kb) |
| CICF Public Assistance Form | PDF (191 kb) | |
| Unclaimed Restitution WC 1 | PDF (143 kb) | Doc (49 kb) |
| Unclaimed Restitution WC 2 | PDF (123 kb) | Doc (53 kb) |
| Unclaimed Restitution & Repayment WC4 | PDF (131 kb) | Doc (47 kb) |
| CICF Annual Report 2012 | PDF (319 kb) | |
| CICF Restitution Payment | PDF (550 kb) | |
| SAFE Request for Payment Form (RPF) | PDF (101 kb) | |
| Notice for Sexual Assault Patients | PDF (58 kb) | |
| Safe Payment Program Policy and Guidelines | PDF (144 kb) |
** Please Note you will need Adobe’s Acrobat Reader or Microsoft Word Reader in order to view some of the documents on this page.