Forms and Resources

Topic 

Topic links to VCF policy

Resources
 

Forms
 

• Document Checklist - Personal Injury - use this checklist if you are filing a claim for yourself, or filing for a deceased individual whose death is not believed to be related to a 9/11-related physical condition.

• Signature Page
• Exhibit A / Exhibit A Deceased Individual - Authorization for release of medical records.

• Registration and Claim Filing Deadlines*
• Definitive Proof of Presence Documentation 

• Third Party Verification Form
• Witness Presence Statement  - use this form for any witness who will provide an affidavit in support of your claim. 
• Victim Presence Statement - an optional form that may be helpful if you have additional information about your presence that is not already provided as part of the claim form responses or in your supporting documents.

• WTC Health Program website
• Review this factsheet for additional information about the differences between the VCF and the WTC Health Program.
• WTC Health Program Disability Evaluation Process*  
• Diagnostic Essentials: Physical Health Conditions guidelines.

• Private Physician Forms - Including Appendix C & D

• Non-Economic Loss Awards and Certified Conditions Fact Sheet
• Required Documents to support Lost Earnings for Certain Unions and Employers
• How to claim Medical Expenses - instructions on how to claim past out-of-pocket medical expenses.

• Exhibit 1 - Social Security Administration Consent Form
• Exhibit B1 - Authorization for release of pension and health information from HIPAA and non-HIPAA entities - this form can be used for both Personal Injury and Deceased Individuals
• Medical Expense Worksheet
• Temporary Past Lost Earnings Worksheet - submit with your claim if the victim is claiming temporary lost earnings due to an eligible condition.

• ACH Payment Information Form and instructions.
• ACH International Wire Transfer Form 

• What to Expect at Your Hearing

You should amend if you are seeking a new determination based on new information.

• How to file an Amendment - instructions on how to file an amendment.
• Amendments and Appeals Detailed explanation of when to amend and when to appeal, including examples.

• Document Checklist – Deceased Victim Claim- use this checklist if you are filing a claim for an individual who is believed to have died as a result of a 9/11-related physical condition.
• Information and Instructions*: steps to take if a Personal Injury claimant passes away after filing the claim. 
• Instructions for Letters of Administration with limitations*  
• Information on appointment of a Personal Representative*
• Documents required when the claimant is not the victim.

• Exhibit A Deceased Individual - Authorization for release of medical records.
• Exhibit E – Notice of filing for deceased individuals.
• Lead Personal Representative Form to be completed if the court has appointed multiple individuals as co-Personal Representatives.
• Appendix A – Additional questions for hard copy claim forms submitted for deceased individuals.

Under the VCF Act, attorneys may not charge any individual more than 10% of the amount of the individual’s VCF award.

If you are working with an attorney, they will receive your payment directly.

• Change of Attorney Form - to add, change or remove an attorney.

• VCF Info Sheet* - a general overview of the program, who can apply, and how to apply.  
• VCF Claim Review Process - an overview of the claim review process.
• VCF New York City Exposure Zone Map
• VCF Just the Facts - a great resource that clarifies some common misconceptions about the VCF.

• Claim Form - Hard Copy PDF-Fillable Form available for those who cannot submit via the Online Claims System.  The VCF will input your answers into the system on your behalf to submit your VCF Claim.
• Claim Information Resolution Form - to resolve data discrepancy issues.
• Collateral Offset Update Form - Instructions for notifying the VCF of new collateral offsets.

• Using the Claim Management System (CMS).
• CMS Acceptable Use Policy.
• Claim Status Definitions - definitions for each claim status in the online system.

• Access the online system to create a new account.
• Login to your existing account