WTC Records Folder 0128 Disaster Information General label, 2001

NYC 9/11 Public Portal Document | Section G - Victim Assistance Information Oid a Victn Assistance Program help you to complete this stiidavi? [| Name of Program OyYes [No i—7) Of Name of Person who helped you VAP, - 10 / D Arencods Telephone Number Li Section H - Employment Information Section Was the Victim employed at the time the crime occurred? DoYes [No Employer Name #1 - | Area code — Telephone Number Address City or Town Stale Zip Code Employer Nama #2 | Areacode — Telephone Number Address Cily or Town Stale Zip Code Section | - Medical Treatment and insurance Information Section Before the Victim's death was medical treatment received a6 a resull of the crime? (yes complate questions that apply) [Yes [No Describe injuries briefly First Treating Hospital | Name Address Firat Treating Ooctor Neme Address Is thera any Medical Insurance? (7 yes, Enter tha name of the insurence provider and policy number or "NONE™) [Yes [No Company Name of Primary Insurance Policy of ID Number . Company Name of Major Medrcal Policy or (D0 Number Medicare Policy of (0 Numpei Medicaid Policy of ID Number Company Name of Workers Compensation Camer Policy of 10 Number Company Name of Auto nance Paobcy or 1D Number Claimant Information - Please Print Claimant Name {Lasi) {First) (Middia) CVB Claim Number (if known) Authorization | HEREBY AUTHORIZE any hospital, physician, or oiher person who attended or examines; any undertaker or person who renders services; any employers of the victim; any police or any municipal authority or state depariment or agency, or public authority; any insurance company or organization; or any other person, firm, agency or organization having knowledge thereof, to furnish the New York State Crime Viclims Board, or its representatives, respect to Ihe incident leading to the victim's personal any and all information, including Worker's Compensation records, with injuries of death, and the claim made herewith (or benefils, incurred for medical, or other ex penses necessary a3 a resull of the injui | HEREBY AUTHORIZE AND DIRECT that if an award is made, that out-of-pocr.et expenses including indebtedness reasonably fy, upon.which the claim is based, and unpaid at the time the decision is made and also attorney's fees as allowed by the Board shall be paid by the Comptroller of the Stata of New York directly to the provider(s) of such services. | HEREBY AUTHORIZE AND DIRECT the Crime Viclims Board to provide information about my claim to the Crime Victims Assistance Program lisled in the Victim Assistance information Section of this affidavil. A photocopy of this authorization shall be considered as effective and valid as the original Signature of Claimant Stale of New York County of On this day of 19 , before me came to me known to be the individual described in and who execuled the foregoing instrument and acknowledged that (s)he exacuted the same . Notary Public CVBMIS-DTO1 Rev 05/15/98 NYC-WTC_000137348