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Fill a Valid New York Claim Template

The New York Claim Form, specifically titled NYC-COMPT-BLA-PI1-B, is a critical document for individuals seeking to file a personal injury claim against the city of New York. Managed by the Office of the New York City Comptroller, this form is essential for presenting the details of an incident that resulted in personal injuries. It provides a structured format for claimants or their attorneys to officially document the event, its outcomes, and to initiate the claims process by electronically submitting it through the Comptroller's website.

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Outline

In the bustling streets of New York City, the process for seeking compensation due to personal injuries or damage involves navigating through a structured legal pathway, starting with the completion and submission of the New York Claim Form. This comprehensive document, a creation of the Office of the New York City Comptroller, plays a pivotal role in formally initiating a claim against the city. It encompasses a broad spectrum of required information, including personal details of the claimant or on whose behalf the claim is being filed, specifics about the attorney if the claimant is represented, and critical incident details like the date, time, and location of the occurrence. Furthermore, it demands a detailed account of the manner in which the incident happened, the nature of injuries or damages incurred (including financial estimations), medical treatment received, and evidence support through witnesses. For incidents involving vehicles, detailed information on the vehicles and insurance must be provided. Importantly, the form sets a strict timeline—a claim must either be resolved or legal action initiated within 1 year and 90 days from the incident date to preserve the complainant's rights. Filled with demands for meticulous details and warnings of legal repercussions for false statements, this form encapsulates the city's methodical approach to handling claims, emphasizing accountability and the right to compensation under the law.

Example - 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.

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Document Attributes

Fact Name	Description
Filing Process	Claims must be electronically filed at the NYC Comptroller's Website.
Timeframe for Legal Action	If a claim is unresolved within 1 year and 90 days from the date of occurrence, legal action must be initiated to preserve rights.
Representation	Claims can be filed on behalf of oneself or someone else, and claimants can be represented by attorneys.
Required Information	Key required fields include claimant and, if applicable, attorney's contact information, date of incident, location, and description of how the claim arose.
Medical Information	Includes dates of first treatment and any emergency room treatment, hospital name, and treating physician's information.
Witness Information	Up to four witnesses' names and contact information can be provided.
Employment Information	If claiming lost wages, information about employment, days lost, and amount earned weekly is required.
Vehicle Information	If involving a NYC vehicle, details about both city and non-city vehicles and drivers are needed.
Governing Law	All claims are subject to New York State laws and regulations governing the process and resolution of personal injury claims.

Guide to Using New York Claim

Filling out the New York Claim Form is a crucial step to take when you've encountered an issue requiring attention from the Office of the New York City Comptroller. Whether it's a personal injury claim or another type of complaint, ensuring that every detail is accurately recorded will streamline the process. The information you provide is the foundation for your claim, and it's essential for the comptroller's office to have a clear understanding of the incident. Remember, if your claim is not addressed within 1 year and 90 days from the date of occurrence, you must initiate legal action to maintain your rights. Here’s how to fill it out:

Specify if you are filing the claim on behalf of yourself or someone else. If filing for someone else, provide their last name, first name, and your relationship to them.
If an attorney is filling out the form, enter the attorney's information, including the firm's name, first and last names, complete address, and contact information.
Fill in the claimant's information section with the claimant's last name, first name, date of birth, social security or Medicare number, date of death (if applicable), phone number, email address, occupation, gender, and if they are a city employee.
Input the date, time, and precise location of the incident. These are required fields that must be accurately completed.
Describe the manner in which the claim arose, making sure to provide as much detail as possible to give the comptroller's office a clear understanding of the incident.
List the items of damage or injuries claimed, including dollar amounts for each. This is vital for assessing the claim.
For the medical information section, provide details about the first treatment, including dates, hospital name, and address, as well as whether the claimant was taken to the hospital by an ambulance.
Enter employment information, if claiming lost wages, including the employer's name, address, workdays lost, and amount earned weekly.
Add information about treating physician and any witnesses, including their names, addresses, and contact details.
If the claim involves a New York City (NYC) vehicle, provide details about the owner of the vehicle the claimant was traveling in, non-city vehicle driver, and any relevant insurance information.
For non-city vehicle information, list the make, model, and year of the vehicle, plate number, and VIN, along with city vehicle information if applicable.
Finally, certify the truthfulness of all information provided by checking the box at the end of the form and sign where indicated. The total amount claimed should be entered without including any symbols like "$" or commas.

After completing the form, review all the information to ensure accuracy and completeness. An incomplete or inaccurately filled-out form can delay the claim process. Once you've verified the information, submit the form electronically via the NYC Comptroller's website, adhering to the given instructions. This is your first step towards addressing your claim with the city, and careful attention to detail here can significantly impact the outcome.

Get Answers on New York Claim

What is a New York Claim Form?

The New York Claim Form, specifically designed for personal injury claims, enables individuals to notify the Office of the New York City Comptroller of an injury or damage for which they seek compensation. This document is essential for officially presenting a case against the city regarding an incident that led to personal harm or property damage.

Who can file a New York Claim Form?

Both individuals representing themselves and attorneys acting on behalf of a client can file a New York Claim Form. If you are filing on behalf of someone else, it is necessary to include detailed information about the claimant, such as their name and your relationship to them.

How do I file a New York Claim Form?

Claim forms must be submitted electronically via the NYC Comptroller's Website. This process ensures a timely and efficient handling of your claim.

What is the deadline for filing a claim?

A claim must be filed within 1 year and 90 days from the date of the occurrence. Failing to submit within this timeframe necessitates initiating legal action to preserve your rights and pursue compensation.

What information is required when filing a claim?

Key details needed include both claimant and attorney information (if applicable), specific details about the incident such as the date, time, and location, description of the incident, any injuries or damages sustained, witness information, and any relevant medical and employment details. Documentation surrounding a NYC vehicle, if involved, is also necessary.

Is an attorney required to file a New York Claim Form?

Having an attorney is not a prerequisite for filing a claim. However, legal representation can provide guidance through the process and ensure all necessary information is accurately presented.

What happens after I submit the form?

Upon submission, the Office of the New York City Comptroller will review the claim. They may contact you or your attorney for additional information or documentation to assess your claim thoroughly.

How should I prepare before filling out the claim form?

Prior to filling out the form, gather all relevant information about the incident, including photographs, medical records, a police report if available, witness statements, and receipts for any expenses incurred due to the injury or damage. This will ensure a comprehensive claim submission.

Can I claim for both personal injuries and property damage?

Yes, it is possible to claim for both personal injuries and property damage. Ensure that all damages are clearly listed in the form with corresponding dollar amounts, where applicable.

What are the consequences of submitting false information?

Intentionally providing false information on a New York Claim Form can lead to criminal penalties and civil liabilities. It is imperative that all submitted information is accurate and truthful to the best of your knowledge and belief.

Common mistakes

Filling out the New York Claim form requires attention to detail. Unfortunately, people often rush through the process, leading to mistakes that can cause delays or even result in a claim being denied. Here are some common errors to avoid:

Incorrect or incomplete personal information: Every field marked with an asterisk (*) is required. Failing to fill out these fields completely, especially important details like your Email Address, Date of Birth, and Social Security Number, can result in your form being returned or not processed.
Not double-checking email addresses: The form requires you to type your email address twice to ensure accuracy. This is a crucial step, as a typo can mean you won't receive important notifications about your claim.
Leaving out details about the incident: The sections that ask for the "Date of Incident," "Time of Incident," "Location of Incident," and the "Manner in which claim arose" need to be filled out with as much precision and detail as possible. Generic descriptions or vague timelines won’t suffice.
Forgetting witness information: If witnesses were present, their details can significantly strengthen your claim. Omitting this information or providing incomplete details about witnesses can weaken your case.
Incorrectly reporting medical information and treatment details: It’s vital to include accurate information about your first treatment date, the medical facility's name, and the address. If you visited the emergency room or had multiple treatments, those dates should be correctly entered as well.
Not specifying employment and lost wages accurately: If you're claiming lost wages, you must provide detailed employment information, including the number of workdays lost and your weekly earnings. Inaccurate or incomplete entries can lead to an incorrect claim amount.

When completing the form:

Take your time to review every section and answer all the required fields.
Double-check your input, especially numerical information like dates and contact numbers.
Keep all relevant documents, such as medical reports and employment records, at hand for reference.

By avoiding these common mistakes, you'll help ensure your New York Claim form is processed smoothly and efficiently. Remember, accuracy and completeness are crucial to a successful claim submission.

Documents used along the form

When dealing with a New York Claim form, particularly for personal injury, it's not uncommon to find yourself navigating through a maze of procedures and paperwork. Submitting a claim form is merely the initial step in what can be an intricate process that requires various other forms and documents to support your case. Understanding these additional documents can provide a more comprehensive overview of the process and help ensure that you're thoroughly prepared for every step.

Medical Records: These are detailed accounts from healthcare providers documenting the injuries sustained and treatments administered. They serve as crucial evidence of the extent and nature of the injuries and their direct relation to the incident.
Police Report: If the incident was reported to the police, a copy of the police report can be invaluable. It includes the officer's observations and recorded statements from witnesses, offering an objective viewpoint of the incident.
Witness Statements: Written accounts from individuals who witnessed the incident can bolster a claim by providing additional perspectives that align with the claimant's account of events.
Photographs of the Incident Scene: Photos taken immediately after the incident help visualize the scene, providing tangible evidence of conditions that contributed to the occurrence.
Proof of Wage Loss: Documents such as pay stubs or a letter from the employer can verify lost wages due to the inability to work because of injuries. This documentation is essential for claims that include lost earnings.
Insurance Correspondence: Communication with insurance companies, including the claimant's and any involved parties' insurers, is critical. These documents can include claim filings, policy information, and any denials or settlements offered.

Gathering and submitting these documents alongside the New York Claim form can significantly impact the outcome of a claim. They not only provide a fuller picture of the incident and its aftermath but also reinforce the credibility of the claimant's account. Accurate and thorough documentation is key to navigating the claims process successfully. By understanding and assembling these essential pieces of information, claim solicitors and individuals can work together toward establishing a compelling case.

Similar forms

The New York Claim Form for personal injury shares similarities with a Workers' Compensation First Report of Injury Form, which is used when an employee gets injured on the job. Both forms collect detailed information about the incident, including the time and place it occurred, along with personal information about the injured party. They also require details on the nature of the injuries sustained and any medical treatment received as a direct result of the incident.

Similar to a Motor Vehicle Accident Report, the New York Claim Form requires specific details about the incident location, parties involved, and the circumstances leading to the claim. Both forms aim to document the incident comprehensively, including information about any vehicles involved. In cases where the personal injury claim arises from a vehicular accident, details such as the make, model, and year of the vehicle, as well as insurance information, are crucial for both.

The Medical Malpractice Claim Form, like the New York Claim Form, necessitates detailed medical information related to the claim. This includes the first date of treatment and the healthcare provider's details. Both forms are critical in establishing the connections between the alleged incident and the resultant injuries or conditions, laying the groundwork for any compensation claims.

A Product Liability Claim Form, which individuals use when harmed by a defective product, and the New York Claim Form both require the claimant to detail the injuries or damages sustained. They track the incident's specifics and outline the nature of the claimant's losses or injuries in a quest for restitution or compensation from responsible parties.

Like an Insurance Claim Form that policyholders fill out to report damage or loss, the New York Claim Form collects detailed information about the incident, including the date, time, and location, along with a description of the claimed injuries or damages. Both types of documents are essential for assessing the claim and determining the amount of compensation or benefits owed.

The Slip and Fall Incident Report, often used by businesses to document instances where someone is injured on their property, parallels the New York Claim Form in its requirement for thorough documentation of where, how, and when the injury occurred. Of particular importance is the narrative of the event's occurrence and the environment or conditions that contributed to the incident.

A property Damage Claim Form, similar to the New York Claim Form, is filled out following incidents that result in damage to personal or real property. Both forms detail the circumstances that gave rise to the claim and list the damage or losses incurred. This documentation aids in the valuation of damages for compensation purposes.

Like a Defamation of Character Claim Form, which is used to allege harmful, false statements that resulted in reputational damage, the New York Claim Form includes sections for the claimant to detail the incident and its impacts meticulously. Though focusing on different types of harm, both forms initiate a formal complaint process and potentially a request for compensation based on the alleged wrongful actions of another.

The Employment Discrimination Complaint Form, used by individuals to allege unfair treatment in the workplace based on protected characteristics, and the New York Claim Form both collect personal information about the claimant and detailed accounts of the incident(s) in question. They serve as the starting point for an investigation or legal process to address the allegations made by the claimant.

Lastly, the Homeowner's Insurance Claim Form, filled out by homeowners to report damages or losses to their property for insurance claims, shares the aspect of requiring detailed information about damages with the New York Claim Form. Both seek comprehensive documentation of the incident's circumstances and the extent of the injuries or damages sustained as a foundation for assessing claims and determining compensation.

Dos and Don'ts

When it comes to filing a New York Claim form, accuracy, and adherence to specific guidelines are paramount. Whether you're navigating the process for the first time or need a refresher, here are some key dos and don'ts to ensure your claim is processed efficiently and effectively.

Do ensure you file electronically at the NYC Comptroller's Website if opting for electronic submission. This streamlines the process and helps avoid postal delays.
Do accurately fill out all required fields denoted by an asterisk (*). These fields are mandatory and failing to complete them could result in your claim being delayed or denied.
Do double-check your email address and other contact information. Communication about your claim will likely be conducted via email, so accuracy is crucial.
Do note the timeline for filing a legal action if your claim is not resolved within 1 year and 90 days from the date of occurrence. Keeping this timeframe in mind is critical to preserving your rights.

Don't guess or estimate dates and times. Ensure all information related to the date and time of the incident is exact to avoid any potential disputes or confusion.
Don't leave sections blank if they are applicable to your situation. If a section does not apply, it is advisable to mark it as 'N/A' rather than leaving it empty.
Don't include dollar signs ($) or commas (,) when entering financial amounts in the form. Such symbols can cause processing issues and may lead to unnecessary delays.
Don't forget to detail the manner in which the claim arose and the specific injuries or damages, including any dollar amounts. This information is vital for the Comptroller's Office to assess your claim.

Keep in mind, the process of filing a claim involves careful attention to detail and strict adherence to procedures. By following these dos and don'ts, you can help ensure your New York Claim form is completed accurately, improving the chances of a favorable outcome for your claim.

Misconceptions

Many people have misconceptions about the New York Claim form process, which can lead to confusion and errors when filing. Here are six common misconceptions and the clarifications to help guide individuals through the process:

Misconception 1: Electronic filing is optional. It's mandatory to file claims electronically at the NYC Comptroller's Website. Paper submissions are no longer the standard method and may not be processed.
Misconception 2: You have unlimited time to file a lawsuit if your claim isn't resolved. There's a specific timeframe within which legal action must be started to preserve your rights – 1 year and 90 days from the date of occurrence. Failing to adhere to this timeline can result in losing the right to pursue legal remedies.
Misconception 3: The form can be submitted without an email address. A claimant or an attorney's email address is required when submitting the form. This ensures communication about the claim is efficient and direct.
Misconception 4: Claim details can be vague. Information about the time, place, and manner in which the claim arose needs to be detailed and specific. Vague descriptions can lead to delays in processing the claim.
Misconception 5: Any damages or injuries can be claimed without documentation. The items of damage or injuries must be clearly listed, including dollar amounts. This involves providing medical information, details of first treatment, and if applicable, information about lost wages and the treating physician.
Misconception 6: Personal representation is not allowed. Individuals can file on their own behalf or on behalf of someone else. If filing on someone else’s behalf, specific information regarding the relationship to the claimant and the representative's details must be provided.

Understanding these points clarifies the claim filing process and helps ensure claims are filed correctly and efficiently.

Key takeaways

Filling out the New York Claim form accurately is crucial for those seeking to file a personal injury claim. Here are key takeaways to help navigate the process:

Claims must be filed electronically via the New York City Comptroller's website, ensuring a streamlined process for claim submission.
There is a critical timeframe to remember; if a claim is not resolved within 1 year and 90 days from the date of the occurrence, legal action must be initiated to preserve the rights of the claimant.
It is possible to file a claim on behalf of another person, but additional information such as their name and your relationship to them will be required.
If the claimant is represented by an attorney, detailed information including the attorney's contact details must be provided.
The form requires specific details about the incident, including the date, time, and exact location, highlighting the importance of keeping accurate records.
Information about the damages or injuries incurred, along with requested dollar amounts for compensation, must be clearly stated.
Details of any witnesses, treatments received, loss of employment wages, and information about involved vehicles (if applicable) are crucial for a comprehensive claim.
Lastly, the accuracy of the information provided is paramount. The form includes a certification that the information is true and correct, with an acknowledgment that any willful falsehoods may lead to criminal penalties and civil liabilities.

This list serves as a basic guide for navigating the complexities of the New York Claim form. It is imperative for claimants to provide thorough and accurate information to support their claims effectively.

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