CICA Claim Form - Start Your Criminal Injury Compensation Claim Online

CICA Application Form

Criminal Injuries Compensation Authority (CICA) Application

Step 1 of 9
Who are you applying for? *
Are you 18 or over? *
What is the reason for your claim? *
Victim Details
Full Name *
Have you ever been known by another name? *
Date of Birth *
Gender *
Phone Number *
Email Address *
Address Line 1 *
Address Line 2
Town/City *
Country *
Postcode *
National Insurance Number
Claimant Details
Full Name *
Gender *
Relationship with Victim *
Phone Number *
Email Address *
Address Line 1 *
Address Line 2
Town/City *
County *
Postcode *
About the person who died
Full Name *
Enter their date of birth *
Enter their date of death *
Address Line 1 *
Address Line 2
Town/City *
County *
Postcode *
Incident Details
Were you a British citizen when the crime happened? *
Select the option that best describes you *
Description of the Incident *
Did the crime happen once or over a period of time? *
When did the crime happen? *
When did it start? *
When did it stop? *
Location of the Incident *
Do you know the offender's identity? *
Was the Crime Reported to Police Force? *
Provide investigating police force name *
Have you made any previous claims or received any other form of compensation or damages in connection with this incident? *
Injury Details
What led to your injuries?
This helps us to make a decision about your claim. It also helps us to make sure the information we get from other places, such as the police, is accurate. You can select more than one answer.
What injuries were sustained due to the physical assault? *
What injuries were sustained due to sexual assault or abuse? *
What injuries were sustained due to domestic or family violence? *
What injuries were sustained due to arson or fire-raising? *
What injuries were sustained due to a terrorist attack in Great Britain? *
What injuries were sustained due to an animal or vehicle? *
What injuries were sustained due to witnessing an incident? *
What psychological injuries were sustained? *
What dental injuries were sustained? *
What other injuries were sustained? *
Did you get any Infection? *
What treatment are you receiving for your physical injuries? *
How have your injuries affected your daily life and routine? *
Has this incident had any effect on your family or social life? *
Did you lose a pregnancy? *
Are you registered with a GP, and have you consulted a GP about your injuries? *
Are you currently receiving medical treatment, or have you received treatment in the past? *
Do you have a disabling mental injury *
Have You Seen a Dentist About Your Injuries? *
Loss of Earnings or Expenses
Employment Status at the Time of the Incident *
If you were not employed at the time of the incident, kindly provide the reason for your unemployment
Have you been unable to work or had a very limited capacity to work due to your injuries? *
Has this been for more than 28 weeks? *
This can be a single period of time or cover several periods of time since the crime.
Details of any lost earnings due to the injury *
Please attach proof of lost earnings or expenses
Details of any out-of-pocket expenses *
Funeral Costs
Type of Application *
Is the claimant paying for any of the funeral costs *
Is anyone else contributing to the funeral costs? *
What is the total cost of the funeral? *
If you are not sure what the total cost is, enter an estimated amount in numbers only, such as 125.50
Have you previously applied for compensation related to this crime? *
Legal Information
Has the victim previously applied in connection with any other crime? *
Has the victim applied for or received any other form of compensation or damages in connection with this crime? *
Do You Currently Have Any Unspent Criminal Convictions? *
Witness Details (If Applicable)
Full Name
Phone Number
Email Address
Witness Statement
Supporting Documents

Attach Documents

Document Name
Select Document
Medical records/Police reports/Photographs of injuries/Any other relevant evidence
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Acknowledgment and Agreement
I hereby give my explicit consent and authority to SFR Solicitors to:

  1. Obtain, request, and receive copies of my medical records and medical reports from my GP, hospitals, or any other healthcare providers as required for my CICA claim.

  2. Contact and share relevant information with the Criminal Injuries Compensation Authority (CICA), the police, and any other relevant authorities or experts involved in processing and supporting my claim.

  3. Use my personal and medical information solely for the purpose of assessing, preparing, and submitting my CICA claim.
By submitting this form, I confirm that:

  1. I have read and understood the Privacy Policy available on this website.

  2. I understand how my personal information will be collected, stored, and used by SFR Solicitors in line with the UK GDPR and Data Protection Act 2018.

  3. I give my explicit consent for SFR Solicitors to process my personal and sensitive data for the purposes of assessing and managing my Criminal Injuries Compensation Authority (CICA) claim.

Signature Field
Name *
Date *
Signature *