Section R10-4-107. Submitting a Claim

A.      If the prerequisites in R10-4-106 are met, a natural person is eligible to submit a claim if the person is:

1.        A victim;

2.        A derivative victim;

3.        A person authorized to act on behalf of a victim or a deceased victim’s dependent; or

4.        A  person  who  assumed  an  obligation   for  or  paid  an expense directly related to a victim’s economic loss.

B.       If a person is eligible under subsection (A) to submit a claim regarding more than one incident of criminally injurious con- duct or act of international terrorism, the person shall submit a separate claim regarding each incident of criminally injurious conduct or act of international terrorism.

C.      If more than one person is eligible under subsection (A) to submit a claim regarding an incident of criminally injurious conduct or act of international terrorism, each person shall submit a separate claim.

D.      To apply for a compensation award, a person who is eligible under subsection (A) shall submit a claim, using a form that is available from the Commission, to the operational unit for the jurisdiction in which the incident of criminally injurious con- duct occurred or to the operational unit for the jurisdiction in which a victim lives if the incident of criminally injurious con- duct is an act of international terrorism or occurred in an area without a victim compensation program. The claimant shall provide the following:

1.        About the victim:

a.        Full name,

b.        Residential address,

c.        Gender,

d.        Date of birth,

e.        Residential and work telephone numbers,

f.         Statement of whether the victim is deceased,

g.        Ethnicity,

h.        Statement of whether the victim is a resident, and

i.         Statement of whether the victim is disabled;

2.        About the claimant if the claimant is not the victim:

a.        Full name;

b.        Residential address;

c.        Gender;

d.        Date of birth;

e.        Residential and work telephone numbers;

f.         Relationship to the victim; and

g.        If there are multiple victims or derivative victims of an incident of criminally injurious conduct or act of international terrorism, the name,  residential address, and date of birth of each, and for derivative victims, the relationship to the victim;

3.        About the crime:

a.        Type of crime;

b.        Statement  of  whether  the  crime  was  related  to domestic violence;

c.        Statement of whether the crime was a federal crime;

d.        Date on which crime was committed;

e.        Date on which crime was reported to law enforce- ment authorities;

f.         Name of law enforcement agency to which the crime was reported;

g.        Name of law enforcement officer to whom the crime was reported;

h.        Law enforcement report number;

i.         Location of crime;

j.         Name of perpetrator, if known; and

k.        Brief description of the crime and resulting injuries;

4.        About a civil lawsuit:

a.        Statement of whether the claimant has or will file a civil lawsuit related to the crime; and

b.        If the answer to subsection (D)(4)(a) is yes, the name, address, and telephone number of the claim- ant’s attorney;

5.        About benefits from collateral sources:

a.        List of the benefits the claimant has received since the incident of criminally injurious conduct or act of international terrorism or is entitled to receive; and

b.        For each benefit identified:

i.         Type of benefit,

ii.        Contact address and telephone number; and

iii.      Claimant’s identification or policy number;

6.        About  the  economic  loss  for  which   compensation  is requested:

a.        Medical expenses. A statement of whether the claim includes medical expenses and if so, the name, address, telephone number, account number, and date of service for each provider;

b.        Mental health counseling and care expenses. A statement of whether the claim includes mental health counseling and care expenses and if so, the name, address, telephone number, account number, and date of service for each provider;

c.        Work loss expenses. A statement of whether the claim includes work loss expenses and if so, the date on which the claimant was first unable to work, date on which the claimant returned to work, total time lost from work, hourly rate of pay, number of hours worked each week, number of hours worked each day, name, address, and telephone number of employer, and name of supervisor;

d.        Funeral expenses. A statement of whether the claim includes funeral expenses and if so, the name, address, and telephone number of the provider and the amount paid; and

e.        Crime scene cleanup expenses. A statement of whether the claim includes crime scene cleanup expenses and if so, the name, address, and telephone number of the provider and the amount paid;

f.         Transportation costs. A statement of whether the claim includes transportation costs and if so, the rea- son for travel as listed under R10-4-108(C)(6) and if mileage is claimed, the date and mileage of each trip; and

7.        The claimant’s dated signature:

a.        Certifying that the claimant is eligible to submit a claim and that the information provided is true and correct to the best of the claimant’s knowledge;

b.        Subrogating to the state and operational unit the claimant’s right to receive benefits from a collateral source;

c.        Authorizing the release of confidential information necessary to administer the claim; and

d.        Authorizing the release to the Program of protected health information that relates to care provided as a result of the criminally injurious conduct or act of

international terrorism and is necessary to verify the claim.

E.       A claimant shall attach the following to the claim form submit- ted under subsection (D):

1.        A copy of all bills, contracts, receipts, and insurance statements relating to each expense claimed under sub- section (D)(6); and

2.        If work loss expenses are claimed, a signed statement on official letterhead:

a.        From the claimant’s employer verifying the informa- tion provided under subsection (D)(6)(c); and

b.        If applicable, from the physician or mental health care provider indicating the claimant:

i.         Was unable to work as a result of being a victim or derivative victim, the length of time the claimant was unable to work, and the date on which the claimant was or will be able to return to work; or

ii.        Is totally and permanently disabled.

Historical Note

Adopted effective December 31, 1986 (Supp. 86-6).

Amended effective October 28, 1994 (Supp. 94-4). For- mer Section R10-4-107 renumbered to R10-4-105; new Section R10-4-107 renumbered from R10-4-109 and amended by final rulemaking at 6 A.A.R. 4727, effective November 20, 2000 (Supp. 00-4). Former R10-4-107 renumbered to R10-4-109; new R10-4-107 made by final rulemaking at 13 A.A.R. 4124, effective January 5, 2008 (Supp. 07-4). Amended by final rulemaking at 18 A.A.R.

3309, effective February 3, 2013 (Supp. 12-4).