Funeral Expense Reimbursement Form Logo
  • Funeral Expense Reimbursement Request

  • 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.
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  • 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.

  • 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

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