Section 26-A1803. PROCEDURE FOR FILING

 

1803.1Unless authorized by the Administration, all claims shall be filed on forms as provided by the Department.

 

1803.2A claim shall be considered filed when the victim submits to the Administration a completed application within one hundred eighty (180) days after the accident occurs.

 

1803.3The application for a claim shall contain the following:

 

(a)Statement(s) to establish eligibility pursuant to § 1802 of this chapter;

 

(b)A statement of the nature of the claim, including whether the claim is for injury, or death benefits;

 

(c)A statement of the claimant's relationship to the victim;

 

(d)A description of the accident and injury or death and the date of accident;

 

(e)The name, address, phone number, social security number, birthdate, sex and marital status of the victim;

 

(f)The name(s), address(s), social security number(s), birthdate(s), sex and marital status of dependents;

 

(g)Out of pocket expenses itemization;

 

(h)Medical expenses;

 

(i)Collateral sources of income or payment of benefits;

 

(j)Income itemization;

 

(k)Monthly expenses itemization;

 

(l)A declaration of subrogation and suit notification to be signed by the claimant;

 

(m)Any information that the Administration may require to adequately evaluate and process the claim; and

 

(n)Any other information that the Administration may require to adequately evaluate and process the claim.

 

1803.4The term "collateral sources" as stated in § 1803.3 (i) shall include, but not be limited to, the following items:

 

(a)Proceeds from an accident policy;

 

(b)Payments from a health benefits or group health plan;

 

(c)Medicare or medicaid;

 

(d)Any other plan or system of payment providing compensation, including but not limited to medical and rehabilitative expenses, wage continuation, or loss benefit or funeral benefits for injury or death as a result of an accident; and

 

(e)Any potential civil action based on the liability of another person, unless a determination is made by the Administration that such civil action would not result in compensating the victim.

 

source

Final Rulemaking published at 35 DCR 7649(October 21, 1988).