Collateral Source Worksheet

Collateral Source Worksheet

Victim Name: Claim Number:

Claimant’s Name:

All Claims

Restitution to Victim

Amt Ordered: $ Paid to Date: $

Balance Owed: $ as of / /

Civil Suit

Pending Settled Atty Name:

Workers Comp. (if incident was on-the-job)

Claims with Medical Expenses

Medical Insurance or Medicare

Policy Number:

T-19 /Medicaid

Claims Involving Automobiles

Car Ins. or UM Coverage for Victim

Policy #: Amt Expected: $

Car Insurance of Defendant

Policy #: Amt Expected:

Car Insuran ce of Driver or Vehicle Owner

(if other than the victim)

Policy #: Name of Insured:

Amt Expected: $

Claims Involving Homicide

Burial Insurance

Policy #: Amt Expected: $

Life Insurance (over $50,000)

Policy #: Amt Expected:

Payable to:

Social Security

Amt Expected: $

Cl aims Involving Work Loss

Retirement

Name of Retirement Plan Amt Expected $

Social Security Disability

Amt Expected: $