Government of Ontario

Social Justice Tribunals Ontario
Providing fair and accessible justice
Criminal Injuries Compensation Board

Applying for Compensation for an Injury Application Form

Link to Application Guide

Please refer to the guide when completing this application form.
The guide contains useful information and assistance for completing this form.
Please type your answers or print them in ink in legible handwriting.

We may award compensation only if you were injured in the Province of Ontario as a result of a violent crime, or while making an arrest or assisting a peace officer with his/her law enforcement duties, or while trying to prevent a crime.
Please refer to the guide for more information about who is eligible for compensation.

Please provide all of the requested information in order to ensure that your application is processed as quickly as possible.
Our contact centre is available to assist you should you have any questions not answered in the guide. Please read the form carefully so you complete only the sections that apply to you.

Send your completed application form to the Board with as much supporting documentation as possible. If you have a restraining order, peace bond, probation order, police records (occurrence report, crown synopsis, record of arrest), Court records (Information/Indictment), victim impact statement, power of attorney, medical or therapy records that support your injuries, invoices and/or original receipts, include these documents with your application. If you do not have these documents, do not wait to mail the application form to the Board. Gather the documents and then mail them to the Board once they become available.

Please only send the Board copies of supporting documents. Do not send original documents.

If there is not enough space in certain parts of the application form, use Part 12, Additional Information section. Remember to include your name on completed attachments and specify the section of the application form the additional information pertains to.

It is important that we receive your application form within two years of the crime taking place. We can extend the two-year limitation when it is warranted, but you will have to request such an extension and explain your reason(s) for the delay in Part 5 of the application. Note: If this application is as a result of a crime of sexual violence or of violence that occurred within a relationship of intimacy or dependency the two year limitation period does not apply.

It is essential that you let us know whenever your address or phone number changes. If we are unable to reach you by phone or mail, your application may be dismissed.

Mail, fax or email your completed application form and supporting documents to the addresses or numbers noted below.
For more information about the Criminal Injuries Compensation Board and the application process, please visit our website.
Website: www.sjto.gov.on.ca/cicb

Criminal Injuries Compensation Board
655 Bay Street, 14th Floor
Toronto ON  M7A 2A3
Tel: 416 326-2900 (within the Greater Toronto Area)
Toll Free: 1 800 372-7463
Fax: 416 326-2883
Toll Free: 1 844 249-1619
Email: info.cicb@ontario.ca

The Victim Support Line (VSL), through FindHelp, provides a province-wide, toll-free telephone information line providing access to information for victims, in the language of their choice, 24 hours a day, seven days a week. If you would like to find out about services in your area, or would like to inquire about organizations that might be willing to assist with the completion of your application, call the Victim Support Line at 1 888 579-2888 (if you live in the Greater Toronto Area, call 416 314-2447) and choose option 1.

Please type your answers or print them in ink in legible handwriting.
A separate application must be filed for each person seeking compensation.

Part 1: Victim Information

The victim is the person who was injured during the crime. A date of birth is needed to avoid confusion with other victims with the same or similar names. As we may need to contact you during business hours, a daytime number would be helpful. If you are filing this application on behalf of someone else, put his/her information in Part 1 and your information in Part 2.






Gender

        











Do you have any concerns with the Board leaving messages
regarding this claim at either of the above phone numbers?

  

What is your preferred method of communication with the Board?
(if you check email, you are consenting to the delivery of personal
information and documents by email)

     

Will you require an interpreter at a hearing?

  

Have you filed an application with the Board before?

  

Would you like to permit someone else to speak with the
Board on your behalf? If so, provide name.


Is the Board authorized to release reports to the
individual named?

  

Is the named individual authorized to update your
contact information with the Board?

  

Is the named individual authorized to request duplicate
letters from the Board?

  

Part 2: Applicant Information (if applicable)

Complete this part only if you are not the crime victim, but you are acting on his/her behalf.

You may be the applicant for a crime victim if:

If you are filing this application as a result of witnessing an extremely violent crime against a close family member, put his/her information in Part 1 and your information in Part 2.





Gender

        












Do you have any concerns with the Board leaving messages
regarding this claim at either of the above phone numbers?

  

Will you require an interpreter at a hearing?

  

What is your preferred method of communication with the Board?
(if you check email, you are consenting to the delivery of personal
information and documents by email)

     

Warning: While we have a variety of security measures in place, it is important to remember that email is not secure. We cannot guarantee the privacy or confidentiality of any information that is sent over the Internet by email as it may not be free from interception by third parties.

Part 3: Legal Representation (for the purpose of this application only)

Complete this part only if you have retained a lawyer, agent or paralegal to assist you with your claim for compensation. If you have retained legal representation for another purpose, such as a criminal or civil proceeding, do not complete this part. By completing this part, you are authorizing the Board to release information about your claim to your legal representative and all further communication will be made with your legal representative.















Part 4: Types of Compensation

This part must be completed to let us know the type of compensation you are seeking. We may award compensation only if you were injured in the Province of Ontario as a result of a violent crime, or while making an arrest or assisting a peace officer with his/her law enforcement duties, or while trying to prevent a crime.

Please check the appropriate box(es)









Part 5: Request for Extension Where Crime Occurred More than Two Years Ago

If you are applying for compensation for an incident that occurred more than two years ago, you must first request that we extend the two-year limitation period. Please check “Yes” and explain your reason(s) for the delay in filing this application. Be sure to complete the rest of the application form. If this application relates to a victim who is under the age of 20, an extension of the limitation period for filing is not required. If this application is as a result of a crime of sexual violence or of violence that occurred within a relationship of intimacy or dependency the two year limitation period does not apply. In those cases, please check “No” and proceed to Part 6 of the application. The Board will render its decision on the extension based on written information you provide including the information you have given in the application form.

Was the crime committed more than two years ago?
(In the case of ongoing abuse, did the abuse end
more than two years ago?)



Part 6: Details of the Crime(s)

We understand recounting the details of the incident(s) may be difficult. This information is needed so that we can properly assess your claim. If you do not remember what happened to you, or cannot provide full details, you may record details that have been provided to you by someone else, such as a police officer, doctor, or a person who witnessed the incident. Documents are key to our assessment.

We are obligated, by law, to make a reasonable attempt to locate and notify the (alleged) offender(s) of your application.
If you have concerns about our notification of an (alleged) offender or any disclosure of personal information to the (alleged) offender, you must tell us during the application process.

Type of Crime (please check all boxes that apply)








Part 6 (A): Single Incident

Complete the following section if you were injured as a result of a single crime/incident. If not, move on to Part 6 (B) to provide details of multiple crimes/incidents/abuse.

Time of the crime/incident

  

Provide specific address where the crime/incident occurred
(Note: it must have occurred in Ontario to be eligible for
compensation)



(Alleged) Offender Information:











Section A: Complete this section if the incident was reported to the police.






Were charges laid by the police?

  

Do you know the outcome of those charges?

  

if Yes, please indicate




Is the police investigation or criminal proceeding ongoing?

  


Did you participate in the police investigation?

  

Did you attend criminal court when required to do so?
(e.g. if you were served with a summons)

  

Section B: Complete this section if the incident was not reported to the police


If the incident occurred when you were a child, was it
reported to a Children’s Aid Society?

  

If there was only one incident, proceed to Part 7

Part 6 (B): Multiple Incidents / Patterns of Abuse

Complete this section only if you were injured as a result of multiple crimes/ incidents (e.g. abused/assaulted repeatedly over weeks, months or years).

If you were abused by multiple individuals or multiple times by the same individual, please complete the following sections for each of the (alleged) offenders. If there were more than three (alleged) offenders, please contact us at 416 326-2900 or 1 800 372-7463 for additional forms.

Information for (Alleged) Offender Number 1







Or, if more than one incident, provide dates



Provide specific address where the incident/abuse occurred
(Note: it must have occurred in Ontario to be eligible for
compensation)




Section A: Complete this section if the incident(s) involving (Alleged) Offender No. 1 was reported to the police.




Were charges laid by the police?



Do you know the outcome of those charges?

  

if Yes, please indicate




Is the police investigation or criminal proceeding ongoing?

  


Did you participate in the police investigation?

  

Did you attend criminal court when required to do so?
(e.g. if you were served with a summons)

  

Section B: Complete this section if the incident(s) involving (Alleged) Offender No. 1 was not reported to the police.


If the incident/abuse occurred when you were a child, was
it reported to a Children’s Aid Society?

  

If there are no more (alleged) offenders or incidents, proceed to Part 7

Information for (Alleged) Offender Number 2







Or, if more than one incident, provide dates



Provide specific address where the incident/abuse occurred
(Note: it must have occurred in Ontario to be eligible for
compensation)




Section A: Complete this section if the incident(s) involving (Alleged) Offender No. 2 was reported to the police.




Were charges laid by the police?



Do you know the outcome of those charges?

  

if Yes, please indicate




Is the police investigation or criminal proceeding ongoing?

  


Did you participate in the police investigation?

  

Did you attend criminal court when required to do so?
(e.g. if you were served with a summons)

  

Section B: Complete this section if the incident(s) involving (Alleged) Offender No. 2 was not reported to the police.


If the incident/abuse occurred when you were a
child, was it reported to a Children’s Aid Society?

  

If there are no more (alleged) offenders or incidents, proceed to Part 7

Information for (Alleged) Offender Number 3







Or, if more than one incident, provide dates



Provide specific address where the incident/abuse occurred
(Note: it must have occurred in Ontario to be eligible for compensation)




Section A: Complete this section if the incident(s) involving (Alleged) Offender No. 3 was reported to the police.




Were charges laid by the police?



Do you know the outcome of those charges?

  

if Yes, please indicate




Is the police investigation or criminal proceeding ongoing?

  


Did you participate in the police investigation?

   -

Did you attend criminal court when required to do so?
(e.g. if you were served with a summons)

   -

Section B: Complete this section if the incident(s) involving (Alleged) Offender No. 3 was not reported to the police.


If the incident/abuse occurred when you were a
child, was it reported to a Children’s Aid Society?

   -

If there were more than three (alleged) offenders, please contact us at 416 326-2900 or 1 800 372-7463 for additional forms.

If there are no more (alleged) offenders or incidents, proceed to Part 7

Part 7: Details of Injuries


Part 8: Medical and / or Treatment Information

Please list the names, addresses and phone numbers of the professionals who treated you as a direct result of your injuries that resulted from the crime(s). This means people like doctors, dentists, hospital or clinic staff, counsellors, therapists and others.

Emergency Treatment




Other Hospital / Clinic Treatment




Medical Doctor / Health Practitioner














Medical Doctor / Health Practitioner














Psychiatrist/Psychologist/Counsellor/Therapist














Psychiatrist/Psychologist/Counsellor/Therapist














Dentist / Dental Specialist














Dentist / Dental Specialist














Any Other Treatment Provider















Any Other Treatment Provider
















Part 9: Compensation from Other Sources

Have you received (or will you receive) compensation
from any other source in respect of this injury?

   -

Have you received any services through the Victim Quick
Response Program (VQRP) in respect of this injury?

   -

If the crime occurred at work and you filed a claim with the
Workplace Safety and Insurance Board (WSIB), did you
(or will you) receive a non-economic loss award?

   -

Has the court ordered the (Alleged) Offender to pay
restitution to you?

   -

Have you commenced a civil court action against
the (alleged) offender?

-




Part 10: Expense Information (if applicable)

Please check all of the expenses that are presently known and any you think you might have in the future. If you do not know the exact cost, tell us how much you think you paid in the “Amount” column shown below.

Are you claiming any expenses as a result of your injury?

  

Please check all boxes that apply


Has this amount been paid?   

Please check if you are attaching original invoices/receipts   


Has this amount been paid?   

Please check if you are attaching original invoices/receipts   


Has this amount been paid?   

Please check if you are attaching original invoices/receipts   


Has this amount been paid?   

Please check if you are attaching original invoices/receipts   


Has this amount been paid?   

Please check if you are attaching original invoices/receipts   


Has this amount been paid?   

Please check if you are attaching original invoices/receipts   


Has this amount been paid?   

Please check if you are attaching original invoices/receipts   



Has this amount been paid?   

Please check if you are attaching original invoices/receipts   







Are any of the claimed expenses covered through other
sources? (e.g. WSIB, ODSP, private insurance, etc.)

   -

Part 11: Loss of Income (if applicable)

Did the crime occur at work?

  

If the crime occurred at work, did you file a claim with
the Workplace Safety and Insurance Board (WSIB)?

   -

Are you claiming a loss of wages/income?



If you are claiming loss of wages/income and you worked for more than one employer, please use the Additional Information section (Part 12) to provide us with details regarding any additional employer(s).

Were you employed when the crime occurred?

  

Were you self employed?

  













Did your injury cause you to miss work?

  


Are you unable to return to work as a result of your injury?

  

Did you, or will you, receive any of the following due to
your injury or while you are caring for an injured person?

  

Please check all boxes that apply















If you are seeking compensation for loss of wages/income as a result of caring for an injured victim, please provide us with your full name, address and telephone number along with details regarding the type of care you are providing below.













Part 12: Additional Information (if applicable)


Part 13: Agreement and Authorization for Release of Information

Please read this part carefully. There are certain conditions that apply when a person makes an application for and receives compensation. It is important that you are aware of these conditions. Your signature below shows that you have read, understood and agreed to what is listed below.

  1. For the purpose of this application, I The Undersigned, hereby consent and authorize:

  2. I Understand that: (a) the Board may notify the authorities mentioned above that I have submitted an application and may also inform them of the Board’s decision; (b) any information submitted to the Board is subject to the Freedom of Information and Protection of Privacy Act and the Statutory Powers Procedure Act; (c) it is my responsibility to inform the Board of any change in my address and that my claim may be dismissed following a period of time if the Board is unable to contact me; (d) my failure to cooperate with law enforcement (police, Crown, criminal court) may result in the denial of my claim; (e) if my behaviour contributed directly or indirectly to my injuries, this may result in the denial of my claim or affect the amount of compensation I receive; (f) payment by the Board is a payment of last resort and as such, I hereby agree, within a reasonable time period, to notify the Board in the event that benefits and/or other funds become available to me as compensation for this injury or death.

  3. I Agree to: (a) give the Board all necessary assistance with respect to the above-noted matters; (b) notify the Board of any change in circumstances that may affect the assessment of my compensation; (c) repay the Board if payments are received from the (alleged) offender (restitution or civil action), insurance, WSIB, or any other government or private agency as compensation for this injury after receipt of payment from the Board.

  4. I Certify that: all the above statements contained in my application are true to the best of my knowledge and belief.

If you have any questions, please contact this office at 416 326-2900 or toll free at 1 800 372-7463 or visit our website at www.sjto.gov.on.ca/cicb for additional information.

The personal information on this form is collected under the authority of the Compensation for Victims of Crime Act, R.S.O. 1990, c.C.24. The principle purpose for which this information will be used is to make a determination of eligibility for an amount of compensation. Please be advised that any information submitted to the Board is subject to the Freedom of Information and Protection of Privacy Act, R.S.O. 1990, c. F.31 and the Statutory Powers Procedure Act, R.S.O. 1990, c. S.22. Any questions regarding the collection of personal information should be directed to the Freedom of Information Coordinator, at the Criminal Injuries Compensation Board, 655 Bay Street, 14th Floor, Toronto, ON  M7A 2A3, Telephone: 416 326-2900 or Toll Free: 1 800 372-7463.

Submission Options: Choose one of the following options to submit this form


Option 1 - Email




Option 2 - Fax/Mail - If you are submitting the completed form by fax or mail, please sign and date below.