New York Claim Template

The New York Claim Form is a document used to file personal injury claims with the New York City Comptroller's Office. This form must be completed accurately and submitted electronically through the NYC Comptroller's website. Timely filing is crucial; if your claim is not resolved within 1 year and 90 days from the date of the incident, you must initiate legal action to protect your rights.

Fill Out New York Claim Now

The New York Claim Form is an essential document for individuals seeking to file a personal injury claim with the New York City Comptroller's Office. This form must be completed accurately and submitted electronically through the NYC Comptroller's website. It is crucial to note that if a claim remains unresolved for more than one year and ninety days from the date of the incident, legal action must be initiated to protect the claimant's rights. The form requires the claimant to indicate whether they are filing on their own behalf or on behalf of another individual, necessitating additional personal information about the claimant and their relationship to the person filing. Required fields include the claimant's name, contact details, and specific details about the incident, such as the date, time, and location. Additionally, the form collects information regarding the nature of the injuries or damages claimed, including medical treatment details and witness information. Claimants must also provide employment information if lost wages are being claimed, as well as insurance details if applicable. Completing this form accurately is vital, as it includes a certification clause confirming the truthfulness of the information provided, with potential legal consequences for false statements.

Misconceptions

Misconceptions about the New York Claim form can lead to confusion and errors in the filing process. Below are four common misconceptions, along with clarifications for each.

All claims can be filed at any time without restrictions. Many individuals believe that they can submit a claim whenever they wish. However, if a claim is not resolved within 1 year and 90 days from the date of the incident, legal action must be initiated to preserve rights.
Only individuals can file claims. Some people think that claims can only be filed by the injured party. In reality, claims can also be submitted on behalf of someone else, provided that the necessary information about the claimant is included in the form.
Filing electronically is optional. There is a misconception that electronic filing is just one of many options. In fact, all claims must be filed electronically at the NYC Comptroller's website, making this method mandatory.
Completing the form is straightforward and does not require attention to detail. While the form may seem simple, it contains several required fields that must be accurately filled out. Missing or incorrect information can delay the processing of the claim or lead to its rejection.

Dos and Don'ts

Things to Do When Filling Out the New York Claim Form:

Provide accurate and complete information in all required fields.
Double-check the date format (MM/DD/YYYY) to ensure correctness.
Include a valid email address for communication purposes.
Clearly describe the manner in which the claim arose.

Things Not to Do When Filling Out the New York Claim Form:

Do not leave any required fields blank.
Avoid using symbols like "$" or "," in the Total Amount Claimed section.
Do not submit the form without reviewing all information for accuracy.
Refrain from providing false information, as it may lead to penalties.

Similar forms

The New York Claim form serves as a crucial document for individuals seeking compensation for personal injuries. It shares similarities with several other legal documents, each designed to facilitate claims and legal processes. Below is a list of nine documents that are comparable to the New York Claim form, highlighting their similarities:

Personal Injury Complaint: This document initiates a lawsuit by outlining the plaintiff's claims against the defendant. Like the New York Claim form, it requires specific details about the incident, injuries, and damages.
Notice of Claim: Often used in governmental claims, this document notifies a public entity of an impending claim. It shares a similar purpose with the New York Claim form, as both must be filed within specific time frames to preserve rights.
Demand Letter: A demand letter outlines the claimant's request for compensation and the basis for the claim. Both documents require detailed information about the incident and the damages incurred.
Settlement Agreement: This document formalizes the terms of a settlement between parties. Like the New York Claim form, it often includes specific details about the claims and the agreed-upon compensation.
Insurance Claim Form: Used to request payment from an insurance company, this form requires detailed information about the incident and damages, similar to the New York Claim form.
Affidavit of Service: This document verifies that legal documents have been delivered to the involved parties. It shares the need for accurate information about the parties involved, akin to the requirements of the New York Claim form.
Medical Records Release Form: This form allows the sharing of medical information relevant to a claim. Like the New York Claim form, it necessitates specific details about the claimant and the incident.
Subrogation Agreement: This document allows an insurance company to pursue recovery from a third party. It often includes similar information about the incident and the parties involved, paralleling the New York Claim form.
Witness Statement: A document where witnesses provide accounts of the incident. Both this statement and the New York Claim form require detailed information to support the claim.

Understanding these similarities can help individuals navigate the claims process more effectively, ensuring they provide all necessary information to support their case.

Preview - New York Claim Form

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.

Attorney is filing.

Attorney Information (If claimant is represented by attorney)

Last Name:

First Name:

Relationship to the claimant:

Claimant Information

Firm or Last Name: Firm or First Name: Address:

Address 2:

City:

State:

NEW YORK

*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

NEW YORK

USA

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
Time of Incident:			Format: HH:MM AM/PM

*Location of
Incident:

Address:
Address 2:
City:
State:	NEW YORK
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

Office of the New York City Comptroller

1 Centre Street

New York, NY 10007

Witness 1 Information

1st Treatment Date:

Hospital/Name:

Address:

Address 2:

City:

State:

Zip Code:

Date Treated in Emergency Room:

Format: MM/DD/YYYY

NEW YORK

Format: MM/DD/YYYY

Last Name:

First Name:

Address

Address 2:

City:

State:

NEW YORK

Zip Code:

Witness 2 Information

Was claimant taken to hospital by	Yes	No	NA
an ambulance?

Employment Information (If claiming lost wages)

Last Name:

First Name:

Address

Employer's Name:

Address

Address 2:

City:

State:

Zip Code:

Work Days Lost:

Amount Earned Weekly:

NEW YORK

Address 2:

City:

State:

NEW YORK

Zip Code:

Witness 3 Information

Last Name:

First Name:

Address

Treating Physician Information

Last Name:

First Name:

Address:

Address 2:

City:

State:

NEW YORK

Zip Code:

Address 2:

City:

State:

NEW YORK

Zip Code:

Witness 4 Information

Last Name:

First Name:

Address

Address 2:

City:

State:

NEW YORK

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:

NEW YORK

Last Name:

First Name:

Address

Address 2:

City:

State:

Zip Code:

NEW YORK

Insurance Information

Non-City vehicle information

Insurance Company Name:

Address

Address 2:

City:

State:

Zip Code:

Policy #:

Phone #:

NEW YORK

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:
	Pedestrian	Bicyclist
	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.

Crucial Queries on This Form

What is the purpose of the New York Claim Form?

The New York Claim Form is used to file a personal injury claim against the City of New York. This form collects essential information about the claimant, the incident, and the damages incurred. It is crucial for individuals seeking compensation for injuries or damages resulting from incidents involving city property or employees. Completing this form accurately ensures that your claim is processed efficiently.

How do I submit the New York Claim Form?

To submit the New York Claim Form, you must file it electronically through the NYC Comptroller's website. This online submission is the preferred method and helps streamline the claims process. Ensure that all required fields are completed before submitting. If you encounter any issues, you can contact the Comptroller's office for assistance.

What happens if my claim is not resolved in time?

If your claim remains unresolved for more than one year and ninety days from the date of the incident, you must initiate legal action to preserve your rights. This means filing a lawsuit within that timeframe. Failing to do so may result in the loss of your right to seek compensation for your injuries or damages.

What information do I need to provide on the form?

The form requires various pieces of information, including:

Your personal details, such as name, address, and contact information.
The date, time, and location of the incident.
A description of how the incident occurred.
Details about your injuries and any medical treatment received.
Information about any witnesses and, if applicable, your employer.

Ensure that all required fields are filled out completely to avoid delays in processing your claim.

How to Write New York Claim

Filling out the New York Claim form is an important step in seeking resolution for personal injury claims. Ensure that all required fields are completed accurately to avoid delays in processing your claim. Below are the steps to guide you through the process of filling out the form.

Begin by indicating whether you are filing on behalf of yourself or someone else.
If filing for someone else, provide their last name, first name, and your relationship to the claimant.
If an attorney is filing the claim, enter the attorney's firm name or last and first name, along with their address, city, state, and zip code.
Fill in the claimant’s information, including their last name, first name, address, city, state, zip code, and country.
Provide the claimant's date of birth, Social Security number, and Medicare number (if applicable).
Indicate the claimant's phone number, email address, and occupation. Specify if the claimant is a city employee and their gender.
Record the date and time of the incident, ensuring to use the correct format (MM/DD/YYYY and HH:MM AM/PM).
Describe the location of the incident, including the address, city, state, and borough.
Explain how the claim arose in the provided section.
List the items of damage or injuries claimed, including dollar amounts.
Provide medical information, including the first treatment date, hospital name, and address.
Indicate if the claimant was taken to the hospital by ambulance.
If claiming lost wages, fill in the employer's name and address, along with the number of workdays lost and the amount earned weekly.
Include information for any treating physicians, including their names and addresses.
If applicable, complete the section regarding NYC vehicle information, including the owner of the vehicle and insurance details.
Finally, enter the total amount claimed, ensuring that all required fields are completed before submission.
Review all information for accuracy, then certify that the information provided is true and correct.

↓ New York Claim File

Common mistakes

Filling out the New York Claim form can be a daunting task, and mistakes can lead to delays or even denials of your claim. One common error is failing to provide complete information in the required fields. Each section marked with an asterisk (*) is crucial. Omitting even one of these details can result in your claim being rejected. Ensure that all mandatory fields are filled out thoroughly.

Another frequent mistake is not adhering to the specified date formats. The form requires dates to be entered in MM/DD/YYYY format. Misplacing a digit or using an incorrect format can lead to confusion and complications. Double-check your entries to avoid this pitfall.

People often overlook the importance of clear and accurate descriptions of the incident. The section asking for the manner in which the claim arose is essential. Providing vague or incomplete information can hinder the processing of your claim. Take the time to explain what happened in detail.

Many claimants forget to include their contact information correctly. An email address is required for both the claimant and their attorney, if applicable. If the email addresses do not match or are entered incorrectly, it can create significant communication issues. Always verify that your contact details are accurate and consistent.

Another common error involves the total amount claimed. The form specifies that this amount can only be entered after completing certain required fields. Failing to follow this guideline can result in confusion during the review process. Make sure to complete the necessary sections first before entering your total claim amount.

People sometimes neglect to include all relevant medical information. This includes the first treatment date and the name of the hospital or healthcare provider. Missing this information can weaken your claim, especially if your injuries are a central part of the case. Document all medical treatments and ensure they are included in the claim.

Inaccurate witness information is another mistake that can affect your claim. If you list witnesses, ensure their names and contact details are correct. Witnesses can provide critical support for your case, and any discrepancies can undermine their credibility.

Lastly, failing to certify the information can lead to significant issues. At the end of the form, you must certify that the information provided is true and correct. Neglecting to do this can result in serious consequences, including potential legal repercussions. Always remember to sign and date the form as required.

Key takeaways

Here are some key takeaways about filling out and using the New York Claim form:

Electronic Filing: Claims must be submitted electronically through the NYC Comptroller's website.
Time Limit: If your claim is not resolved within 1 year and 90 days, you must take legal action to protect your rights.
Claimant Information: You can file on your own behalf or on behalf of someone else. Be prepared to provide the necessary details about the claimant.
Required Fields: Certain fields are mandatory. These include claimant's name, email, date of incident, and location of the incident.
Incident Details: Clearly describe how the incident occurred and provide the date, time, and location.
Medical Information: Include details about medical treatments received, including dates and hospital names.
Witness Information: Provide contact details for any witnesses to the incident, if available.
Employment Information: If claiming lost wages, include your employer's information and the amount you earn weekly.
Insurance Details: If applicable, provide the insurance company’s name and policy number related to the incident.
Total Amount Claimed: You can only enter this amount after completing all required fields. Do not include symbols like "$" or ",".

Filling out the form accurately is crucial. Any false statements may lead to serious legal consequences.

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Document Attributes

Fact Name	Details
Governing Authority	The New York Claim Form is governed by the laws of the State of New York.
Filing Location	Claims must be electronically filed at the NYC Comptroller's website.
Time Limit	If a claim is not resolved within 1 year and 90 days from the date of occurrence, legal action must be initiated to preserve rights.
Claimant Options	Individuals can file on their own behalf or on behalf of someone else, providing necessary information about the claimant.
Required Fields	Key fields marked with an asterisk (*) must be filled out to complete the form.
Certification Statement	Filers must certify that the information provided is true and correct, acknowledging potential penalties for false statements.