Funeral Expense Reimbursement Form

We extend our deepest condolences to you and your family for the loss of your loved one.

The Program covers a maximum of $5,000 for funeral and burial expenses.

Instructions: Complete this form to initiate the claim process for a deceased claimant and to initiate a processing for outstanding claims and benefits. Your request will be forwarded to a team member for review and processing with a response within 24-48 hours.To file a claim for the grief/funeral expense, there are two options:

1. Reimbursement (After the funeral) - Submit the Program's Claim Reimbursement Form, the funeral/burial invoice, and a copy of the expense receipt.

2. Direct Billing (At the funeral's time) - Check the box below requesting the Program for direct billing to a funeral home or burial facility.

Documentation Required

Obtain the required documentation prior to completing this form. Examples include:

Obtain proof that burial insurance did not cover the costs.
Obtain an itemized bill/invoice for the expenses.
Obtain dated receipt for the expenses showing claimant paid the expenses.
Van title (if owned) that must be transferred to the Program and return the van within 90 days of the claimant's date of death.

Claimant Name*

First NameLast Name

Claimant's Date of Death*

Date

Person Completing this Form*

First NameLast Name

My relationship to the claimant is_________*

Phone Number*

Area CodePhone Number

Email*

example@example.com

Program Benefits

Van/Transportation Benefit

The Program requires the claimant's family to work with Program staff to arrange the return of the Program's van. Any percentage of the van owned by the Claimant will be processed and the Program will issue payment to the Claimant's family, designated entity, or recipient.

Did the claimant have a van issued by the Program for the transportation benefit?*

YesNoUnknown

If the claimant had a Program van, has it been returned to the Program? Note: If the claimant has a van, it must be returned to the Program within 90 days of the claimant's date of death

YesNoUnknown

Indicate what percentage of ownership you have, please indicate that amount below. If unknown, type N/A.

Example: 10 percent

Does the claimant have outstanding van insurance reimbursement claims?

YesNoUnknown

Other Program Benefits

The Program pays for eligible existing/outstanding claims through the date of the claimant's death.

Upload any outstanding claims to the Program via the link below or mail a paper copy to the Program's office at Virginia Birth-Related Neurological Injury Compensation Program, 7501 Boulders View Drive, Suite 600, Richmond, VA 23225. NOTE: Per the Virginia Code, all claims must be submitted within one year of the incurred expense.

1. Complete the Program's Claim Reimbursement Form.

2. Provide the required documentation including:

a. death documentation - a death certificate, obituary, or documentation from an independent source confirming the admitted claimant’s demise

b. funeral, burial, or memorial items - funeral, headstone, casket, cremation, urn; but not memorial jewelry

Does the claimant have outstanding claims to submit? This includes therapies, medical treatment, etc. See the Program Handbook for more information at https://www.vabirthinjury.com/claimantsfamilies/.

YesNoUnknown

Upload the Program Claim Reimbursement Form, receipt for eligible claims. (Note: You may drag/drop or click on the "Browse Files" button to submit up to 25 documents.

Browse Files

Acceptable submissions include PDF or JPG files

Does the claimant have outstanding time sheets to submit for any caregivers (family or independent care) for reimbursement?

YesNoUnknown

Did the claimant have an agency/agencies providing caregiving services?

YesNoUnknown

Agency Name(s) (if known)*

If not, write N/A

Did the claimant have the wage benefit?

YesNoUnknown

Did the claimant reside in a Trust Home?

YesNoUnknown

Did the claimant pay primary health insurance annually or did the Program pay monthly premiums?

Annual payments were made by the claimantMonthly premiums were made by the ProgramUnknown

Is there a funeral/burial claim to submit for the claimant's eligible grief benefit? Note: The claim is up to a maximum of $5K. There is no end-date to submit this claim.

YesNoUnknown

Have you submitted a prior or partial $5,000 reimbursement for this benefit?

YesNo

Upload the Program Claim Reimbursement Form, receipt for funeral/burial expense, and a copy of the funeral home/burial receipt paid for the claimant.

Browse Files

Acceptable submissions include PDF or JPG files

Questions?

0/160

Funeral Expense Reimbursement Request