empowering the severely brain injured and their families via support, understanding and a network of care
Does the beneficiary remain in residential care or in receipt of a home care package funded by the NHS and/or social services?YesNo
Is the beneficiary in receipt of Personal Independence Payments? If so, please specify whether this is for:Care:YesNo[group group-392 inline]Standard RateHigher Rate[/group] Mobility:YesNo[group group-677 inline]Standard RateHigher Rate[/group]
Compensation Claims
1. Has any claim for compensation been made?YesNo[group group-583 inline]1.1. Is the claim ongoing?OngoingSettled successfullyUnsuccessfulN/A[/group] 2. Has a claim been filed with the Criminal Injuries Compensation Authority? YesNo[group group-933 inline]2.1. Is the claim ongoing? OngoingSettled successfullyUnsuccessfulN/A[/group]
State Benefits
Has the applicant applied for and been refused: Local Authority Community Equipment grant?YesNo Local Authority Minor Adaptations Grant?YesNo Local Authority Disabled Facilities Grant YesNo Employment Support AllowanceYesNo Personal Independence PaymentsYesNo Attendance AllowanceYesNo
Insurance Policies
Does (or has) the beneficiary have any entitlement to make a claim under a policy of insurance for critical illness, accident benefit or Permanent Health Insurance by reason of the brain injury suffered?YesNo
Documents Required in Support
I attach the following documents in support: Evidence of injury (hospital discharge summary or similar)YesNo[group group-342 inline][/group] Evidence of current state benefits receivedYesNo[group group-493 inline][/group] Evidence of refusal of state benefitsYesNo[group group-764 inline][/group] Evidence of refusal of local authority grantsYesNo[group group-176 inline][/group] Evidence of expense incurred or to be incurredYesNo[group group-100 inline][/group]
I confirm that the contents of this application and accompanying documents are true to the best of my knowledge and belief. I understand and agree that:
(i) I may be required to produce upon request documentary evidence of expenditure for which a grant is sought;(ii) I may be required to repay to Brain Injury is BIG any part or the whole of any grant made that is not utilised for the purpose for which a grant is sought;(iii) I will be required to repay to Brain Injury is BIG the whole of any grant paid and any reasonable costs of recovery following any application that is willfully or recklessly dishonest.
Signature
Please send completed application form to: Brain Injury is BIG grant scheme, Brain Injury is BIG, 182 Goldsworth Road, Woking, Surrey, GU21 6NF
All applications will be considered by the trustees of Brain Injury is BIG who have absolute discretion and whose decision shall be final. Where applicable payments will be made directly to the supplier.
