RESS ieuiress, Oty, crab. Bp code) S WAGE LOSS COVERED BY INSURANCE? LI YES NO S VtAGE LOSS COVERED BY WORKER'S COMPENSATION? YES TELEPHONE ) NJMEER IS VICTIM DISABLED AS A RESULT OF THE CFdME7 YES 11 NO n NO Section 4. Loss of Support Information or Grief Counseling Information Micate the n