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Claim Form for Physical Injury

Claim Form for Physical Injury

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Published by Michael_Lee_Roberts

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Published by: Michael_Lee_Roberts on Oct 15, 2012
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05/13/2014

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AURORA VICTIM RELIEF FUND PROGRAMCLAIM FORM – FOR PHYSICAL INJURYDEADLINE FOR SUBMISSION OF THIS FORM IS NOVEMBER 1, 2012
 
To assist us in responding to your claim as soon as possible, please help us bycompleting the information requested in the form below. If you need assistance incompleting this form, please call or email Phyllis Hanfling atPhyllis.hanfling@state.co.us
 
(303) 866-6395
SECTION 1. VICTIM INFORMATION
First Name: MI:
 
Last Name:
 
SSNNumber: / Street Address 1Street Address 2City State Zip CodeTelephone Number (Day) Telephone Number (Evening/Cell)
SECTION 2. VICTIMS CIRCUMSTANCES ON JULY 20, 2012
 
Present in Century 16 Multiplex Theater in Theater 8 or 9
 
Present in Century 16 Multiplex Theater Complex
SECTION 3. INFORMATION REGARDING THE VICTIMS PHYSICAL INJURIES
(
complete this Section if you were physically injured on July 20, 2012)
 
Were you hospitalized overnight as a result of your injuries sustained on 7/20/12? Yes
No
 Enter the total number of days and nights of hospitalization during the period between 7/20/12 andOctober 15, 2012? ________________ 
SECTION 4. MEDICAL INFORMATION
Please provide a brief description of your injuries:Did your injuries result in permanent paralysis or brain injury? Yes
No
 I have attached documentation to verifythe length of my hospitalization (forexample, a letter from the hospital or healthcare provider).Yes
No
 

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