Victim page

Required information:

✓ Name

✓ DOB

✓ Social security number

• NOTE: There is a box you can select if you don’t have a SSN

✓ Mailing address

• NOTE: This must be an official USPS postal address. Make sure the name of your street and zip code are entered correctly. If the address is incorrect, it may prevent you from officially submitting the claim application.

NOTE:

• If you are the victim, you will not need to fill out the Claimant page.
• You can request an interpreter here.
• If you are an advocate assisting a victim in completing this application, answer “yes” to the question, “are you the victim?”
• Undocumented crime victims are also eligible for compensation.

Claimant page

NOTE:
You will only complete the Claimant page if:

• You are a legal guardian of a victim who is:
  • Under 18, or
  • Physically or mentally incapable of signing the claim form
• You are filing a death claim

Someone who has the authority of a POA (Power of Attorney) should not complete this page. The POA may sign the claim on behalf of the victim. The victim’s information should be entered on the Victim page and the question “Are you the victim?” should be marked as “Yes”.

Required information on the Claimant page:

✓ Name

✓ DOB

✓ Social security number

• NOTE: There is a box you can select if you don’t have a SSN

✓ Mailing address

• NOTE: This must be an official USPS postal address. Make sure the name of your street and zip code are entered correctly. If the address is incorrect, it may prevent you from officially submitting the claim application.

NOTE:

• You can request an interpreter here.

Crime page

Required information:

✓ Claim type

✓ Crime Report #

✓ Police or criminal justice agency crime was reported to

✓ County crime happened

✓ Date of crime

✓ Date crime was reported

✓ Explanation if there are more than 7 days between date of crime and date it was reported

✓ Explanation if more than one year between date of crime and date this claim is being filed

✓ Description of crime

Answering the question, “The victim ______________ due to this crime.”

The way you answer the question, “The victim ____________ due to this crime” will determine what type of claim you will be applying for.

There are three types of OVS victim compensation claims:

• Death claims
• Essential personal property claims
• Personal injury claims

You are eligible for different kinds of reimbursements based on the type of claim you make.

Although it seems straightforward and easy, knowing the correct answer to this question can be complicated. For example, even if the victim was not physically injured, they may still be eligible for a personal injury claim depending on certain factors.

For help determining what type of claim you are eligible for:

Please go to Victim Compensation Claim Assistance App developed by the NY Crime Victims Legal Network to help you understand the type of claim you qualify for and the kinds of reimbursements you can request.

You can also see the OVS Compensation Training Series videos on “Personal Injury Claims” and “Essential Personal Property Claims” to help you determine which type of claim you should apply for.

Once you know what type of claim you qualify for, it is important to answer the following question accurately:

       “The victim _________________ because of the crime.”

Select:

• “lost essential personal property” If you are applying for an Essential Personal Property Claim.
• "was injured” if you are applying for a Personal Injury Claim.
• “died” if you are applying for a Death Claim.

What to do if you don’t have a police report but you have another qualifying document:

• Submit a copy of your police report or other qualifying document along with your claim.
• You can provide additional information in the “Describe the crime in your own words” section or on a separate document which you can attach in your claim.

Note:

• One of the biggest mistakes applicants make is filing for the wrong claim. Please make sure you answer the question, “The victim ___________ as a result of the crime” correctly.
• Once you select an answer for the above question, the claim type will appear on top of each of the pages. Depending on what claim you are applying for, you will have access to different pages.
• Describing the crime and explaining what happened to you again may be traumatic. Remember, you can refer to the crime report, keep your statement brief, and ask help from a victim assistance program.
• Refer to your police report or other criminal justice document to answer the crime the victim has experienced.
• It is a “domestic violence crime” if the victim and the suspect:
  • Are related
  • Are married or dating
  • Were married or dating
  • Have a child in common
• Victims of Human Trafficking with a police report or OTDA/DCJS letter should apply for a Personal Injury claim. This is because injury is presumed.
• A hate crime is a crime motivated by bias (such as gender, race, sexual orientation, religion, age, disability, national origin, etc.).
• If you are unsure if the crime is a hate crime, select Unknown.
• Personal injury claims will need documentation of injury sustained and treatment provided.
• Essential personal property claims will need original receipts of lost or damaged property or replacement costs.
• If more than 7 days have passed between the date of the crime and the date you are filing this claim, you will have to explain why.
• If more than one year passed between the date of the crime and the date you are filing this claim, you will have to explain why.

Suspect Page

Complete this page even if you don’t know the name of the suspect or if the suspect hasn’t been arrested or prosecuted for this crime.

Note:
If you receive restitution from the suspect in criminal court, you will be expected to repay OVS for any compensation you received.

Expenses page

Indicate the expenses related to this crime.

Note:

• “DV shelter” indicates your out-of-pocket expenses related to staying at a domestic violence shelter.
• You will need original receipts to prove expenses.
• There may be a maximum amount OVS can give you for compensation.

Essential Personal Property page

Note:

• You can submit your claim without the names, policy numbers, and deductibles of your homeowner/renter or auto insurance, but you will be asked for this later.
• You will be asked for original receipts for items that were lost or damaged, or receipts to replace these items.
• There may be a maximum amount that OVS can give you for compensation. The maximum award for a cash loss is $100, and the total maximum award for loss of essential personal property is $500.

Lost Wages page

You will only be asked to complete this page if your claim is a Personal Injury Claim. You will not be able to access this page if you are filing for an Essential Personal Property Claim.

Required information:

✓ Employer information

✓ Contact information of doctor who certified you could not return to work after the crime

✓ Name and policy/id # of any insurance company that will cover your lost time at work

• Unemployment insurance
• Disability insurance
• Pension Plan
• Worker’s compensation
• Other insurance
• Social Security Benefits
• SSI benefits

NOTE:

• If the victim or parent of a minor is self-employed, you must submit last year’s federal tax returns and schedules with your application.
• If you want to be reimbursed for lost wages, you must allow OVS to contact your employer and complete the Employer information.
• You will need a doctor’s letter certifying that the victim could not return to work as a result of the crime. The letter should also indicate the date range that the victim was unable to work.
• For Loss of Support on a death claim, you must:
  • Provide documentation proving the deceased victim’s income (such as OVS employment questionnaire, or Federal Tax Return if self-employed or business owner),
  • Provide proof of your dependence on the deceased victim (such as marriage license, birth certificate, documentation to prove principle support), and
  • Disclose any reimbursement (such as social security/supplemental income decisions, workers’ compensation decision, pensions, employer/union benefit, leave accruals)

Burial Expenses page

You will only be asked to complete this page if your claim is a Death Claim and if you have any burial expenses.

Providers page

You will only be asked to complete this page if your claim is a Personal Injury Claim. You will not be able to access this page if you are filing for an Essential Personal Property Claim.

Complete this page if you were injured and required medical treatment.

NOTE:

• Although not a required field in the portal, if you sought treatment, list who your providers are. If you do not have the names and addresses of the medical professionals treating you at the time of application, OVS will contact you later for this information.
• Documents needed for reimbursement of expenses include:
  • medical records and doctors note completed by provider and sent directly to OVS,
  • mental health treatment report completed by provider and sent directly to OVS
  • itemized bills
  • payment receipts AND
  • if applicable, explanation of benefits (EOB) from claimant’s insurance carrier

Dependents page

You will only be asked to complete this page if your claim is a Personal Injury Claim. You will not be able to access this page if you are filing for an Essential Personal Property Claim.

Only complete this page if you are requesting compensation for a dependent.

Required information:

✓ Social security numbers of all your dependents (people who depend on you for support)

NOTE:

• You can still apply if your dependents don’t have a social security number.

Counseling page

You will only be asked to complete this page if your claim is a Personal Injury Claim. You will not be able to access this page if you are filing for an Essential Personal Property Claim.

Complete this page only if a dependent listed on this claim received counseling because of the crime.

Required information:

✓ Insurance company name and policy or ID number

✓ Name of counselor

NOTE:

Documents needed for reimbursement of counseling expenses include:

• mental health treatment report completed by provider and sent directly to OVS
• itemized counseling bills
• payment receipts AND
• if applicable, explanation of benefits (EOB) from claimant’s insurance carrier

Insurance page

You will only be asked to complete this page if your claim is a Personal Injury Claim. You will not be able to access this page if you are filing for an Essential Personal Property Claim.

Required information:

✓ Insurance company name and policy or ID number

• Primary insurance
• Major medical insurance
• Other insurance (union, vision, dental)
• Medicare
• Medicaid
• Workers’ compensation
• Auto insurance
• Other insurance

Note:

• Every insurance question requires a YES or NO answer.
• If you submit your application without providing homeowner, rent, or auto insurance company names, policy numbers, or deductibles, OVS will ask for these later.

Death Benefits page

Required information to complete this page:

✓ Life Insurance company name, policy or ID number, address, and phone

✓ Company name, policy or ID number, address and phone of other coverage

✓ Pension plan

✓ Other insurance

✓ Medicaid

✓ Workers’ Compensation

Required documents for death claim include:

✓ Criminal justice agency report

✓ Contact info of detectives or DA’s office, AND

✓ Copy of death certificate

NOTE:

• If the death is vehicle related, you must include Auto Insurance information in both the INSURANCE page and on the Death Benefits page. Please include No Fault/MVAIC (Motor Vehicle Accident Indemnification Corporation through NY State). The insurance information can be included in the “Other Insurance” section or in the “If any other insurance or death benefits, list here” field in the Death Benefits page.

• Claimant may be eligible to receive Emergency Awards for loss of support* which results in hardship, and for funeral expenses.

*For Loss of Support on a death claim, you must:

• Provide documentation proving the deceased victim’s income (such as OVS employment questionnaire, or Federal Tax Return if self-employed or business owner),
• Provide proof of your dependence on the deceased victim (such as marriage license, birth certificate, documentation to prove principle support), and
• Disclose any reimbursement (such as social security/supplemental income decisions, workers’ compensation decision, pensions, employer/union benefit, leave accruals)

Financial Situation page

You will only be asked to complete this page if your claim is a Personal Injury Claim. You will not be able to access this page if you are filing for an Essential Personal Property Claim.

You must complete all the sections on this page. Your application cannot be submitted without completing this page. You may enter “0” in the “Assets” fields.

Required information:

✓ Number of dependents

✓ Total annual income from all sources

✓ Assets

• Savings, stocks, bonds
• Real property
• Proceeds from life insurance
• Other

✓ Debt

• Mortgage
• Loans
• Other

Private Lawyer page

NOTE:

• Complete this page if an attorney is helping you file this claim or is representing you in a civil suit related to the crime.
• Do not include the names of the District Attorney or Assistant District Attorney prosecuting the criminal case.
• If you obtain monetary damages from the suspect after suing them in civil court, you will be expected to repay OVS for any compensation you received from them.

Representative page

You can give permission to someone to talk to OVS about your claim. This person is an “authorized representative.” An advocate, attorney, or a family member can be an authorized representative.

Note:

• OVS will only speak to authorized individuals regarding this claim.