empowering the severely brain injured and their families via support, understanding and a network of care
1. Has any claim for compensation been made?YesNo1.1. Is the claim ongoing?OngoingSettled successfullyUnsuccessfulN/A 2. Has a claim been filed with the Criminal Injuries Compensation Authority? YesNo2.1. Is the claim ongoing? OngoingSettled successfullyUnsuccessfulN/A
Has the applicant applied for and been refused: Local Authority Community Equipment grant?YesNo Local Authority Minor Adaptations Grant?YesNo Local Authority Disabled Facilities Grant YesNo Employment Support AllowanceYesNo Personal Independence PaymentsYesNo Attendance AllowanceYesNo
Does (or has) the beneficiary have any entitlement to make a claim under a policy of insurance for critical illness, accident benefit or Permanent Health Insurance by reason of the brain injury suffered?YesNo
I attach the following documents in support: Evidence of injury (hospital discharge summary or similar)YesNo Evidence of current state benefits receivedYesNo Evidence of refusal of state benefitsYesNo Evidence of refusal of local authority grantsYesNo Evidence of expense incurred or to be incurredYesNo
(i) I may be required to produce upon request documentary evidence of expenditure for which a grant is sought;(ii) I may be required to repay to Brain Injury is BIG any part or the whole of any grant made that is not utilised for the purpose for which a grant is sought;(iii) I will be required to repay to Brain Injury is BIG the whole of any grant paid and any reasonable costs of recovery following any application that is willfully or recklessly dishonest.
