Forms and Filing


How to Apply

1. Fill out the application form

There are two separate application forms: one for a violent crime that resulted in an injury and one for a violent crime that resulted in a death.

By computer: Save the application form to your computer. Type your answers in the application form, saving your answers as you go. Use Adobe Reader 7.0 or a higher version.

By hand: Print out the application form and guide, or, if we sent you forms, use those. Make sure we can read your writing.

Refer to the guide when you complete the application form. Call us if you have questions in the guide.

Read your answers to make sure they are correct.

Sign and date the last page.

2. Include these documents with your application if you have them:

  • restraining order
  • probation order
  • victim impact statement
  • power of attorney
  • death certificate
  • medical or therapy records that demonstrate your injuries
  • invoices and/or receipts for costs related to the injury or death, e.g. medical costs, funeral costs

If you do not have these documents, do not wait to send your application to the CICB. Send your application and then gather the other documents.

When we get your application, we’ll send you a letter with your case number. Include your case number on any documents you send us.

3. Make copies of your application form and any supporting documents that you send to us for your records. Send us the copies and keep the originals for yourself. The documents you send us will not be returned to you.

4. Send us the completed form and any supporting documents.

5. Remember to contact us if your address or phone number changes. If we can’t reach you by phone or mail, your application may not be processed.

Forms and Guides

Applications

You can use the html or PDF version of the form. If you use the PDF, right click on the PDF icon, select “Save link as” and then open the form on your computer. Do not open the forms directly in your browser (e.g. Chrome, Safari) because some browsers will not let you complete or save the form.

The application forms and guides are below. If you need a form in an alternate format, such as braille or large print, contact us.
Application Form for an Injury pdf icon PDF HTML (Completed form cannot be saved)
Guide for "Application Form for an Injury" pdf icon PDF HTML
Application Form for a Death pdf icon PDF HTML (Completed form cannot be saved)
Guide for "Application Form for a Death" pdf icon PDF HTML

Notice of Change of Address

Use this form to let us know if your contact information changes while we are processing your application. It’s important to keep your phone number and address up to date. If we are can’t reach you, it will delay your application and could even cause your application to be dismissed.

Send us the form by email, fax or mail. If you are emailing the form, check the box to apply your electronic signature. If you fax or mail the form, remember to sign and date it.

Notice of Legal Representation

Use this form to give your legal representative permission to communicate with the CICB about your case and access the information on your file. If you choose to have a legal representative, the CICB will only communicate with that person and not with you.

Authorization for Authorized Party

Use this form to give someone other than your legal representative permission to communicate with the CICB about your case and access the information on your file.

Direction of Funds

Use this form to tell the CICB that you want your legal representative to receive award money on your behalf.

Consent to Disclose Personal Health Information

The CICB routinely requests medical information in order to assess your injuries. Healthcare providers like doctors and hospitals usually require your written consent before they will share those documents with the CICB. Use this form to give your consent.

Verification Form

Give this form to your treatment provider to submit counselling, physiotherapy, dental, chiropractic or massage therapy treatment expenses for payment. Your treatment provider must attach invoices to the form that show the details of the service provided and the cost. Do not use this form unless you have received written permission from the CICB to submit these expenses in advance. Any expenses you submit that the CICB has not pre-authorized will not be paid.