CICA Online Application Form Title First Name Last Name Email Phone Number Address Line 1 Address Line 2 Town Postcode Date of Birth Town/Place Of Birth On the date of the incident giving rise to the criminal injury, I was ordinarily resident in the United Kingdom.? YesNo If no, please provide further details National Insurance Number Occupation At Time Of Incident Date Of Incident Time Of Incident Postcode Of Incident Incident Address OR Location Name (If known) of person who assaulted you Incident Description (What Happened) Was the incident reported to the police? YesNo Date incident reported to police Time incident reported to police Details (name/address) of police station Crime reference number Officer name/ Collar number Who reported the incident to the police? Did you make a police Statement? YesNo Has the assailant been identified by the police? YesNoDon't know Did the police take a statement? YesNo Was the offender prosecuted? YesNoDon't know Describe your injuries Did you attend your GP surgery YesNo Date of visit/s to GP GP surgery name & address Did you attend hospital as a result of this incident? YesNo Date of visit/s to hospital Hospital name, address & treating department Are you willing to take this matter to court? YesNoDon't Know Is the matter going to court? YesNoDon't Know If yes please provide the court date Has the matter gone to court? YesNoDon't Know If yes please provide the court date Have you received any treatment for your injuries? YesNo If you have received treatment please give details Do you have any criminal conviction/s, including simple cautions and reprimands, in the UK or abroad? YesNo If Yes, please give details Have you been diagnosed with a phycological condition/s? YesNo If Yes, please give details Do you have any unspent criminal condition/s? YesNo If Yes, please give details If you have a criminal conviction please provide the following information - country / offence / sentence / Date of sentence YesNo If Yes, please give details Have you ever applied for a criminal compensation before? YesNo If Yes, please give details As a direct result of your injury, did you have no, or a very limited, capacity for paid work for a period exceeding 28 weeks? YesNo If Yes, please give details As a direct result of your injury, did you incur costs for ‘special expenses’ such as treatment, care, special equipment? YesNo If Yes, please give details Were you and the assailant living together as members of the same family when the incident took place? YesNo If Yes, please give details Have you claimed or do you intend to claim compensation from any other source for the same incident? YesNo Any additional information