Section 80-2-004 - EnclosuresThe following documents and information must accompany all applications:
004.01 Medical and/or Mental Health - Itemized billing statements for related medical and/or mental health services provided to the victim, which are directly related to the incident for which compensation is being requested. If requested by the program, all medical and/or mental health reports relating to the incident for which compensation is being requested must be submitted.004.02 Wages - A signed statement from the employer identifying the dates of work missed due to the incident; the individual's hourly wage; the number of hours worked weekly by the individual; the total amount of the individual's deductions; and the frequency of payment must be submitted when loss of wages is being claimed. A copy of the doctor's release is required.004.02A Loss of Earning Power - If the claim is for loss of earning power for the victim, the following information is required: earning information from the victim's employer and income tax returns for the previous two years; written relevant medical information from the medical providers regarding the diagnosis, prognosis, and degree of disability; the amount of time the victim will be unable to work; and any other information determined to be relevant by the Hearing Officer or Committee.004.02B - Maintenance of the Victim - If the claimant is requesting funds for the maintenance of the victim, the claimant must submit a copy of the doctor's written statement requiring such services; the reason(s) the victim requires such services; and the dates such services are required. 004.03 - Funeral and Burial - If funeral expenses are claimed, a copy of the death certificate of the victim and all itemized statements relating to the funeral and burial expenses of the victim must be included. Food, alcohol, and flowers are not reimbursable expenses.004.04 - Loss of Support - If the applicant is claiming compensation for pecuniary loss for dependent(s) of a deceased victim, the applicant must provide the Committee or Hearing Officer legal documentation that said applicant is the conservator of the estate of the deceased and has conservatorship for the dependent(s).80 Neb. Admin. Code, ch. 2, § 004
Amended effective 12/7/2019Amended effective 7/28/2021