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Application for Reimbursement

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APPLICATION FOR REIMBURSEMENT
CLIENT SECURITY FUND

STATE OF CONNECTICUT
JUDICIAL BRANCH

JD-GC-15 Rev. 1-15

P.B. §§ 2-68, 2-70 through 2-78

www.jud.ct.gov

ADA NOTICE

The Judicial Branch of the State of Connecticut complies with the Americans with Disabilities Act (ADA). If you need a reasonable accommodation in accordance with the ADA, contact a court clerk or an ADA contact person listed at www.jud.ct.gov/ADA.

Instructions

  1. Review the information contained in the pamphlet The Client Security Fund Answers to Your Questions (Form JDP-GC-16) before completing this form. The pamphlet is available from the office of the Client Security Fund Committee or online at http://www.jud.ct.gov/Publications/GC016.pdf.
  2. Provide the following information requested as completely as possible. If more space is needed, attach additional pages.
  3. Submit copies of any documentation that you believe proves your loss, such as cancelled checks, receipts, letters, closing statements, etc. with your completed form. Do not submit original documents, as they will be made part of the file and will not be returned.
  4. The form must be signed by you, and any other named claimant, under oath before a notary public or other authorized official.
  5. Mail the completed application, and any supporting documents, to the address shown below. Applications that are incomplete may be returned without further review.

To: Client Security Fund Committee, 2nd Floor, Suite One, 287 Main Street, East Hartford, CT 06118-1885

1. Your Name (First, Middle, Last)

Mr. Ms. Other

Address (Number, street, town and zip code)

Telephone Number

E-mail Address

2. Name, address and telephone number of the attorney whom you claim dishonestly and/or fraudulently has taken your money or property:

3. What legal services did you ask this attorney to perform for you? Please note that the fund may only reimburse losses that occurred in the course of an attorney-client relationship or in a fiduciary capacity arising out of an attorney-client relationship.

4. Describe the attorney's dishonest and/or fraudulent conduct (attach additional pages if necessary). Please note that in order for a claim to be reimbursable, it must involve conduct on the part of your attorney in the nature of a theft, embezzlement or the wrongful taking of money or property. In limited circumstances the committee may reimburse a loss based on an attorney's refusal to refund unearned fees paid in advance. Losses that are the result of negligence, malpractice, or investment services provided by the attorney are not covered by the client security fund:

5. State the amount of loss you claim should be reimbursed by the client security fund:

6. Did your loss involve: ("X" proper box or boxes)

Money Securities Other property (Specify below):

7. Can your loss be reimbursed from any other source, such as insurance, fidelity bonds or surety agreements? (“X” proper box)

No Don't know Yes (If yes, describe this source below):

8. How much did you pay this attorney? (Please include copies of any documents that are evidence of your payment or payments)

9. Did you have a written fee agreement with the attorney? (If yes, attach a copy of the agreement.)

Yes No

10. Describe what steps you have taken to recover the loss directly from the attorney, or any other source. Provide the date or dates when you took such steps (for example, if you filed a civil action, provide the date the action was filed):

11. State the date when the loss of your money or property occurred (State how and when your loss was discovered):

Please note that a loss presented more than four years after the loss was discovered or should have been discovered ordinarily is not reimbursable by the client security fund:

12. Answer the following questions to the best of your knowledge ("X" proper box) Please note that losses are not covered by the client security fund unless you have been awarded a judgment against the attorney, or the attorney that caused the loss has died, been adjudged incapable, been disbarred or suspended from the practice of law, has resigned from the practice of law, or been placed on probation or inactive status:

a. Has the attorney died?

No Yes, give date: Unknown

b. Has the attorney been adjudged incapable?

No Yes, give date: Unknown

c. Has the attorney been disbarred or suspended from the practice of law?

No Yes, give date: Unknown

d. Has the attorney resigned from the practice of law?

No Yes, give date: Unknown

e. Has the attorney been placed on probation or inactive status by a Connecticut court?

No Yes, give date: Unknown

f. Have you been awarded a judgment against the attorney?

No Yes, give date: Unknown

13. This loss has been reported to: ("X" proper box or boxes)

State's Attorney Police Statewide Grievance Committee

Attach a copy of your complaint and describe what action was taken.

14. State the names and addresses of any witnesses or individuals having information concerning your claim:

Name of Witness or Individual 1

Address of Witness or Individual 1 (Number, street, town and zip code)

Telephone Number of Witness or Individual 1

Name of Witness or Individual 2

Address of Witness or Individual 2 (Number, street, town and zip code)

Telephone Number of Witness or Individual 2

15. Are you related to the attorney you claim caused your loss, or are you an associate, partner, or employee of the attorney?

No Yes (If yes, state your relationship with the attorney):

16. Name, address and telephone number of your present attorney:

Notice

The Practice Book rules governing claims filed with the Client Security Fund Committee do not permit attorneys who help clients process claims with the Fund to charge legal fees for that service, except with the permission of the Client Security Fund Committee. If it is determined that you should be reimbursed by the client security fund, you will be required to sign a document transferring your claim against the attorney to the Client Security Fund Committee, to the extent of the award made to you. By signing below, you agree to cooperate in the investigation of your claim and in the investigation of any related disciplinary or criminal proceedings, and you agree to cooperate with the Client Security Fund Committee in any action undertaken to recover amounts paid to you from the client security fund.

I, the undersigned, under oath say: I am the claimant in the above matter; I have read the foregoing and know the contents thereof; and I certify that the same is true of my own knowledge, except as to the matters and things which are therein stated upon my information and belief, and that as to those matters and things, I believe them to be true.

Signed (Claimant)

Date signed

Subscribed and sworn to before me on:

Date

At (Town)

Signed (Commissioner of Superior Court, Notary Public)

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What the Application for Reimbursement Is and When You Need It

An Application for Reimbursement is a formal request submitted to a payer, insurer, employer, or program administrator seeking repayment for expenses incurred on behalf of an individual or organization. Typical use cases include employee expense reports, healthcare cost reimbursement, grant or program reimbursements, and vendor-initiated cost recoveries. The form documents claimant identity, expense details, supporting receipts, authorizing signatures, and remittance instructions so the payer can validate, approve, and process payment.

Why a Complete Application for Reimbursement Matters

A clear, accurate application reduces processing delays, lowers the risk of denial or recoupment, and provides an evidentiary record for audits and tax reporting. Proper formatting and complete supporting documentation improve traceability and help meet statutory or payer filing windows.

Why a Complete Application for Reimbursement Matters

Who Typically Prepares and Approves These Applications

Different stakeholders require specific data and authorization levels; confirm signer authority and required attachments before submission.

  • Employees and contractors submitting expense reimbursement requests for travel, supplies, or client costs.
  • Patients or providers filing medical cost reimbursements for insurance or benefit plans.
  • Grant recipients requesting payment for allowable project expenses.

Primary Signer Roles

Claimant

The individual or entity claiming reimbursement. Must supply identity, dates, itemized expenses, original receipts, bank or mailing details, and a signature attesting to accuracy and truthfulness.

Approver

A manager, program officer, or claims processor with delegated authority to verify expense legitimacy, apply policy rules, and authorize payment; approver information and signature are required for final payment authorization.

Core Components to Include on a Professional Application for Reimbursement

A complete application groups claimant identity, expense detail, supporting documentation, authorization, and remittance instructions to streamline validation and payment.

Claimant Information

Full legal name, taxpayer ID or employee number, contact information, and mailing and bank details for disbursement; mismatches can delay payment and trigger backup withholding.

Expense Line Items

Date, description, category, unit cost, quantity, and total for each item. Itemization enables policy checks and audit trails.

Supporting Receipts

Attach original receipts, invoices, or proof of payment. For electronic submissions, PDF or image attachments must be legible and clearly labeled.

Authorization and Signatures

Claimant signature and approver signature with printed names and dates. When required, notarization or witness blocks should be present.

Policy and Coding

Policy code, account or grant number, GL coding, or benefit plan identifier for routing to the correct payment source.

Audit Information

Document ID, submission date, processing status fields, and an audit trail for approvals and edits to support internal controls.

Step-by-Step: Fill, Approve, and Submit Your Reimbursement Request

Follow these sequential actions to complete and deliver an application that payers can process without follow-up.

  • 01
    Prepare Documentation: Gather receipts, invoices, and policy references before starting the form.
  • 02
    Complete Fields: Enter claimant details, itemized expenses, and totals using required formats.
  • 03
    Obtain Authorization: Secure required manager or program officer approval and signature.
  • 04
    Submit and Track: Send to the payer via the required channel and retain confirmation for audit.

How to Configure an Online Reimbursement Workflow

Online workflows reduce manual steps; configure fields, authentication, routing, and attachments to match your internal policy.

Field Configuration
Signature Authentication Email link | SMS code | KBA optional
Conditional Fields Show receipts upload when amount > $50
Approval Routing Manager approval then finance review
Attachment Limits Accept PDF, JPG; max 10 MB per file

Where to Send or File Your Completed Application

Identify the payer-specific endpoint before submission; routing rules differ by employer, insurer, or grantor.

  • Employer Portal: Upload within the payroll or expense system per internal policy.
  • Insurer Claims Desk: Submit to the insurer's claims address or secure portal.
  • Grant Administrator: Send via the program's electronic grants management system.
  • Mail or Email: Use certified mail or payer-specified secure email when portal submission is not available.

Digital Signing and eSubmission: Technical Considerations

Confirm the recipient accepts electronic submissions and that your platform retains a tamper-evident audit trail meeting ESIGN/UETA requirements.

  • File Formats: PDF | DOCX accepted
  • Authentication: Email, SMS, or stronger
  • Integrations: CRM and storage connectors

Common Preparation Mistakes to Avoid

  • Submitting illegible or partial receipts forces manual review and delays payment by days or weeks.
  • Incorrect or inconsistent claimant names and taxpayer IDs can trigger backup withholding or denial.
  • Omitting policy codes, account numbers, or required approvals creates routing errors and rework.
  • Failing to use the payer's required submission channel often results in lost or unprocessed claims.

Consequences of an Incorrect or Incomplete Application

Claim Denial: Payer may refuse reimbursement
Recoupment: Previously paid amounts may be recovered
Tax Withholding: Backup withholding can apply
Fraud Liability: Civil or criminal exposure
Audit Risk: Increased likelihood of audit
Processing Delays: Longer turnaround times

Typical Timelines and Processing Expectations

Processing windows vary by payer and program; confirm specific submission deadlines in policy or plan documents.

Submission Window:

Often 30–90 days from expense date

Acknowledgement:

Receipt confirmation within 1–5 business days

Initial Review:

7–30 days depending on volume

Final Payment:

Typically 30–60 days after approval

Appeal Period:

Varies by payer; check policy

Key Milestones from Submission to Payment

Track these sequential milestones so you can follow up at predictable intervals.

01

Prepare and Submit

Complete form and upload supporting receipts for submission.

02

Acknowledgement Received

Confirm the payer logged your submission and has your document ID.

03

Claims Review

Payer validates eligibility, coding, and approvals.

04

Payment Issued

Payer disburses funds by check or electronic transfer.

Real-World Examples of Electronic Reimbursement Workflows

Organizations across sectors use electronic forms and eSignature to speed approvals and ensure compliance.

Fertility Centers of Illinois

airSlate SignNow provided flexible signing and secure workflows for patient-facing forms.

  • The team cited reliability and compliance with healthcare requirements.
  • As a result the clinic improved document handling across mobile and desktop, reduced manual intake steps, and maintained HIPAA protections while shortening turnaround times.

Martin Properties

Property managers moved tenant and vendor reimbursements online to avoid in-person signature collection.

  • The founder noted improved compliance and remote execution.
  • The shift eliminated paper delays, enabled remote approvals, and produced auditable records that simplified month-end reconciliation for accounting.

Security and Compliance Basics to Protect Reimbursement Records

Encryption: TLS 1.2/1.3 in transit, AES-256 at rest
Audit Trail: Comprehensive timestamps and IP logging
Certifications: SOC 2 Type II and ISO 27001
Regulatory: ESIGN, UETA, HIPAA (BAA required)
Accessibility: WCAG 2.0 Level AA
Payment Security: PCI DSS certified handling

Representative eSignature Pricing and Feature Comparison

Compare basic starting prices and common feature availability for typical eSignature vendors; signNow appears first for parity in column ordering.

signNow DocuSign Adobe Sign PandaDoc HelloSign
Starting Price $8/user/mo $15/user/mo $14/user/mo $19/user/mo $15/user/mo
Free Trial Yes, 7-day trial Varies by plan Varies by plan Varies by plan Varies by plan
Bulk Send Yes Yes Yes Yes No
Audit Trail Yes Yes Yes Yes Yes
HIPAA Compliant Yes Yes Yes No No
Envelope Cap No envelope cap 100 envelopes/user/year Varies by plan Varies by plan Varies by plan

Frequently Asked Questions About the Application for Reimbursement

Answers to common questions about completing, signing, and submitting reimbursement applications, with practical guidance on next steps.


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