New York Claim Form PDF Details

In navigating the complexities of filing a personal injury claim in New York, understanding the intricacies of the New York Claim Form becomes paramount for claimants or attorneys representing them. Managed by the Office of the New York City Comptroller, located at 1 Centre Street, New York, NY 10007, this form serves as a crucial first step in seeking redress for injuries sustained due to various incidents within the city's jurisdiction. With provisions for electronically submitting claims via the Comptroller's website, it emphasizes a stringent timeline wherein unresolved claims within 1 year and 90 days from the date of the occurrence must proceed to legal actions to protect the claimant's rights. Catering to both self-representing claimants and those utilizing legal representation, it gathers comprehensive data including personal, attorney, medical, employment, witness, and insurance information alongside details concerning the incident such as time, location, and the manner in which the claim arose. The form also uniquely addresses scenarios involving city vehicles, specifying owner and insurance details for both city and non-city involved vehicles, and culminates in a declaration to affirm the accuracy and truthfulness of provided information under penalty of law, highlighting the seriousness with which these claims are processed and investigated.

QuestionAnswer
Form NameNew York Claim Form
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other nameslottery claim form required for winnings, new york claim form, forms for small claims in new york city ny, lotto claim form

Form Preview Example

Office of the New York City Comptroller

1 Centre Street

New York, NY 10007

Form Version: NYC-COMPT-BLA-PI1-B

Personal Injury Claim Form

Electronically filed claims must be filed at the NYC Comptroller's Website. If your claim is not resolved within 1 year and 90 days from the date of occurrence you must start legal action to preserve your rights.

I am filing: On behalf of myself.

On behalf of someone else. If on someone else's behalf, please provide the following information.

Last Name:

First Name:

Relationship to the claimant:

Claimant Information

Attorney is filing.

Attorney Information (If claimant is represented by attorney)

Firm or Last Name:

Firm or First Name:

Address:

Address 2:

City:

State:

*Last Name:

*First Name:

Address:

Address 2:

City:

State:

Zip Code:

Country:

Date of Birth:

Soc. Sec. #

HICN: (Medicare #)

Date of Death: Phone:

*Email Address:

*Retype Email Address:

Occupation:

City Employee?

Gender

Format: MM/DD/YYYY

Format: MM/DD/YYYY

Yes No NA

Male Female Other

Zip Code: Tax ID: Phone #: *Email Address:

*Retype Email

Address:

The time and place where the claim arose

*Date of Incident:

 

Format: MM/DD/YYYY

Time of Incident:

 

 

Format: HH:MM AM/PM

 

 

 

 

 

 

*Location of

 

 

Incident:

 

 

Address:

Address 2:

City:

State:

Borough:

* Denotes required fields. A Claimant OR an Attorney Email Address is required.

Office of the New York City Comptroller

1 Centre Street

New York, NY 10007

*Manner in which claim arose:

* Denotes required field.

Office of the New York City Comptroller

1 Centre Street

New York, NY 10007

The items of damage or injuries claimed are (include dollar amounts):

Medical Information

1st Treatment Date:

Hospital/Name:

Address:

Address 2:

City:

State:

Zip Code:

Date Treated in Emergency Room:

Format: MM/DD/YYYY

Format: MM/DD/YYYY

Office of the New York City Comptroller

1 Centre Street

New York, NY 10007

Witness 1 Information

Last Name:

First Name:

Address

Address 2:

City:

State:

Zip Code:

Witness 2 Information

Was claimant taken to hospital by

Yes

No

NA

an ambulance?

 

 

 

Employment Information (If claiming lost wages)

Employer's Name:

Address

Address 2:

City:

State:

Zip Code:

Work Days Lost:

Amount Earned

Weekly:

Treating Physician Information

Last Name:

First Name:

Address:

Address 2:

City:

State:

Zip Code:

Last Name:

First Name:

Address

Address 2:

City:

State:

Zip Code:

Witness 3 Information

Last Name:

First Name:

Address

Address 2:

City:

State:

Zip Code:

Witness 4 Information

Last Name:

First Name:

Address

Address 2:

City:

State:

Zip Code:

Office of the New York City Comptroller

1 Centre Street

New York, NY 10007

 

Complete if claim involves a NYC vehicle

Owner of vehicle claimant was traveling in

Non-City vehicle driver

Last Name:

First Name:

Address

Address 2:

City:

State:

Zip Code:

Last Name:

First Name:

Address

Address 2:

City:

State:

Zip Code:

Insurance Information

Insurance Company Name:

Address

Address 2:

City:

State:

Zip Code:

Policy #:

Phone #:

Non-City vehicle information

Make, Model, Year

of Vehicle:

Plate #:

VIN #:

City vehicle information

Plate #:

City Driver Last

Name:

Description of

Driver

Passenger

City Driver First

claimant:

Pedestrian

Bicyclist

Name:

 

 

 

Motorcyclist

Other

 

Total Amount

Claimed:

The Total Amount Claimed can only be entered once the following required fields are entered:

Claimant Last Name

Claimant First Name

Claimant Email or Attorney Email

Date of Incident

Location of Incident

Manner in which claim arose

Format: Do not include "$" or ",".

I certify that all information contained in this notice is true and correct to the best of my knowledge and belief. I understand that the willful

making of any false statement of material fact herein will subject me to criminal penalties and civil liabilities.

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So as to finalize this PDF form, make certain you provide the right details in every single field:

1. It is crucial to complete the lottery claim form required for winnings correctly, therefore be mindful when working with the segments containing all these blank fields:

Stage no. 1 in filling in ny lottery claim form pdf

2. Once your current task is complete, take the next step – fill out all of these fields - Location of Incident, Format MMDDYYYY, Soc Sec, HICN Medicare, Date of Death, Phone, Email Address, Retype Email Address, Occupation, City Employee, Yes, Gender, Male, Female, and Other with their corresponding information. Make sure to double check that everything has been entered correctly before continuing!

Retype Email Address, Format MMDDYYYY, and Email Address inside ny lottery claim form pdf

3. Completing Manner in which claim arose is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

Best ways to complete ny lottery claim form pdf stage 3

4. Completing The items of damage or injuries is crucial in the next step - ensure to don't hurry and fill out every single blank!

Writing section 4 of ny lottery claim form pdf

Be really attentive when completing The items of damage or injuries and The items of damage or injuries, because this is where a lot of people make some mistakes.

5. The final step to submit this document is integral. You must fill out the mandatory fields, like Medical Information, Witness Information, st Treatment Date, Format MMDDYYYY, HospitalName, Address, Address, City, State, Zip Code, Date Treated in Emergency Room Was, Format MMDDYYYY, Yes, Employment Information If claiming, and Employers Name, prior to submitting. Neglecting to do so may give you a flawed and probably nonvalid document!

Yes, Employment Information If claiming, and State of ny lottery claim form pdf

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