Outline
The New York Claim form, officially known as the Personal Injury Claim Form, is an essential document for individuals seeking compensation for injuries sustained in incidents involving the City of New York. This form must be filed electronically through the NYC Comptroller's website. It includes crucial sections that require detailed information about the claimant, including their personal details, the nature of the claim, and specifics surrounding the incident. Claimants must specify whether they are filing on their own behalf or on behalf of someone else, which necessitates additional information about the individual they represent. The form also requires a description of the incident, including the date, time, and location, as well as the manner in which the claim arose. It is important to note that if the claim remains unresolved for over one year and ninety days from the date of the incident, legal action must be initiated to protect the claimant's rights. Furthermore, the form collects data on damages claimed, medical treatment received, and witness information, all of which are vital for processing the claim effectively. By providing accurate and comprehensive information, claimants can ensure their claims are properly evaluated and addressed.
Sample - New York Claim Form
Office of the New York City Comptroller
1 Centre Street
New York, NY 10007
Form Version:
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
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: |
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Format: MM/DD/YYYY |
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Time of Incident: |
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Format: HH:MM AM/PM |
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*Location of |
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Incident: |
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Address: |
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Address 2: |
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City: |
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State: |
NEW YORK |
Borough: |
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* 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? |
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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 |
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
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: |
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Motorcyclist |
Other |
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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.
Form Information
| Fact Name | Fact Details |
|---|---|
| Governing Law | The New York City Claim Form is governed by New York City Administrative Code. |
| Filing Location | Claims must be filed electronically at the NYC Comptroller's Website. |
| Time Limit for Legal Action | If unresolved within 1 year and 90 days, legal action must be initiated. |
| Claimant Options | The form allows filing on behalf of oneself or another individual. |
| Required Fields | Fields marked with an asterisk (*) are mandatory to complete the form. |
| Incident Information | Details about the date, time, and location of the incident must be provided. |
| Medical Information | Claimants must include treatment details, including hospital names and dates. |
| Witness Information | Up to four witnesses can be listed, with their contact details required. |
| Employment Details | If claiming lost wages, employer information and workdays lost must be included. |
| Certification Statement | Claimants must certify the accuracy of the information provided in the form. |
Detailed Guide for Filling Out New York Claim
After completing the New York Claim form, it is essential to ensure all required fields are filled accurately before submission. This form is crucial for initiating a claim regarding personal injury. Once submitted, the claim will be processed, and you will receive further instructions or updates regarding your case.
- Determine if you are filing on your own behalf or on behalf of someone else.
- If filing for someone else, provide their last name, first name, and your relationship to them.
- If an attorney is filing, fill out the attorney's firm name, last name, first name, and contact information.
- Complete the claimant's information, including last name, first name, address, city, state, zip code, date of birth, social security number, and email address.
- Indicate if the claimant is a city employee and their occupation.
- Fill in the details of the incident, including the date, time, and location of the incident.
- Describe how the claim arose in the specified field.
- List the damages or injuries claimed, including dollar amounts.
- Provide medical information, including the date of first treatment and the hospital's name and address.
- Include witness information for up to four witnesses, providing their names and addresses.
- If applicable, indicate whether the claimant was taken to the hospital by ambulance.
- If claiming lost wages, provide the employer's name and address, along with work days lost and weekly earnings.
- Fill out treating physician information, including names and addresses.
- If the claim involves a NYC vehicle, provide details about the vehicle owner and driver, including names and addresses.
- Complete the insurance information, including the company name, address, policy number, and phone number.
- For non-City vehicles, provide details about the vehicle's make, model, year, plate number, and VIN.
- Calculate and enter the total amount claimed, ensuring all required fields are completed beforehand.
- Certify the accuracy of the information by signing the form.
Obtain Answers on New York Claim
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What is the purpose of the New York Claim form?
The New York Claim form is used to report personal injury claims against the City of New York. It serves as an official document to notify the city of an incident that resulted in injury or damage, allowing the claimant to seek compensation for their losses.
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How do I file the claim electronically?
To file the claim electronically, you must visit the NYC Comptroller's website. There, you will find the necessary instructions and resources to submit your claim online. Be sure to have all required information ready before starting the process to ensure a smooth submission.
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What happens if my claim is not resolved within the specified time frame?
If your claim is not resolved within one year and 90 days from the date of the incident, you are required to start legal action to preserve your rights. It is important to keep track of these deadlines to avoid losing your opportunity for compensation.
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What information is required on the claim form?
The claim form requires several key pieces of information, including:
- Your personal details (name, address, contact information).
- The details of the incident (date, time, location, and manner in which the claim arose).
- Information about damages or injuries claimed, including medical treatment received.
- Witness information and any employment details if claiming lost wages.
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Can I file a claim on behalf of someone else?
Yes, you can file a claim on behalf of someone else. However, you will need to provide specific information about the claimant, including their name and your relationship to them. This ensures that the claim is properly attributed and processed.
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What if I do not have all the required information at the time of filing?
While it is best to provide all required information when filing your claim, you can still submit the form with the information you have. However, missing information may delay the processing of your claim. It is advisable to gather as much information as possible before submission.
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How do I determine the total amount to claim?
The total amount claimed should reflect the damages or injuries incurred as a result of the incident. This includes medical expenses, lost wages, and any other relevant costs. Ensure that you do not include symbols like "$" or "," when entering the amount on the form.
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What should I do if I have questions about the claim process?
If you have questions about the claim process, it is best to contact the Office of the New York City Comptroller directly. They can provide guidance and clarify any uncertainties you may have regarding your claim or the filing process.
Common mistakes
When completing the New York Claim form, individuals often encounter several common pitfalls that can hinder the processing of their claims. One significant mistake is neglecting to fill out all required fields. Essential information, such as the claimant's last name, first name, and email address, must be provided. Failing to do so can result in delays or even rejection of the claim.
Another frequent error is not using the correct format for dates and times. The form specifies that dates should be entered in the MM/DD/YYYY format and times in HH:MM AM/PM. Inaccuracies in these formats can create confusion and may lead to complications in the processing of the claim.
Additionally, many claimants overlook the importance of providing detailed descriptions of the incident. The section asking for the manner in which the claim arose is crucial. A vague or incomplete description can make it difficult for the reviewing authorities to understand the context of the claim.
Claimants sometimes fail to specify the total amount being claimed. This figure must be entered after completing all required fields. It is important to note that the total amount claimed should not include symbols such as "$" or ",". Misrepresenting this information can lead to further complications.
Another common mistake is the omission of medical information. Claimants should include details about their first treatment date, the hospital or medical facility visited, and any other relevant medical information. This data is vital for substantiating the claim and demonstrating the extent of injuries or damages.
Furthermore, individuals often forget to provide accurate witness information. Witnesses can play a crucial role in supporting a claim, so including their names and contact details is essential. Without this information, the claim may lack the necessary support to be taken seriously.
Some claimants also make the mistake of not indicating whether they were taken to a hospital by ambulance. This detail is important as it can impact the assessment of damages and the overall validity of the claim. It is a simple yet significant piece of information that should not be overlooked.
Lastly, individuals sometimes fail to certify the information provided on the form. This certification is a declaration of the truthfulness of the information submitted. Neglecting to sign or certify can lead to serious legal repercussions, including potential criminal penalties. It is crucial to ensure that all information is accurate and complete before submitting the claim.
Documents used along the form
The New York Claim form is an essential document for individuals seeking to file a personal injury claim against the city. However, several other forms and documents are often needed to support the claim process. Below is a list of these documents, each playing a crucial role in ensuring that the claim is properly filed and processed.
- Notice of Claim: This document formally notifies the city of the intent to pursue a claim. It must be filed within 90 days of the incident and includes basic details about the claim.
- Medical Records Release: A signed authorization allowing healthcare providers to share medical records with the city. This is vital for substantiating claims of injury and treatment.
- Employment Verification Form: This form confirms the claimant's employment status and income details, especially important if lost wages are part of the claim.
- Witness Statements: Written accounts from individuals who witnessed the incident can provide valuable support for the claim. These statements should detail what the witnesses saw and heard.
- Incident Report: If applicable, a report generated by law enforcement or city officials documenting the incident. This can serve as an official account of the events that took place.
- Insurance Information: Documentation regarding any insurance coverage related to the incident, including policy numbers and contact information for the insurance company.
- Photographic Evidence: Photos of the incident scene, injuries, or damages can help visually support the claim. It’s important to gather this evidence as soon as possible.
- Claimant's Statement: A detailed narrative from the claimant describing the incident, the injuries sustained, and how the incident has affected their life.
- Settlement Demand Letter: A letter outlining the claimant's demand for compensation, including a breakdown of damages and the total amount sought.
- Affidavit of Service: A document proving that the Notice of Claim and other relevant documents were properly served to the city or involved parties.
Each of these documents plays a vital role in the claims process, helping to ensure that all necessary information is provided and that the claimant's rights are protected. Proper preparation and submission of these documents can significantly impact the outcome of a claim.
Similar forms
- Personal Injury Complaint Form: This document initiates a personal injury lawsuit, similar to the New York Claim form, as it requires details about the incident, the parties involved, and the damages claimed.
- Notice of Claim: This form is often required in New York before filing a lawsuit against a municipality. It shares the need for specific incident details and claimant information, just like the New York Claim form.
- Medical Authorization Form: This document allows the release of medical records. Both forms require medical information to substantiate claims, emphasizing the importance of medical evidence in personal injury cases.
- Demand Letter: This letter outlines the claim and demands compensation. It is similar to the New York Claim form in that it details the incident and the damages sought, aiming to resolve the matter before litigation.
- Settlement Agreement: This document finalizes the terms of a settlement. It parallels the New York Claim form by requiring a clear statement of damages and the parties involved to ensure mutual understanding.
- Insurance Claim Form: This form is used to request compensation from an insurance company. Like the New York Claim form, it requires specific details about the incident and damages to process the claim effectively.
Dos and Don'ts
When filling out the New York Claim form, it’s essential to approach the process with care. Here are five things to do and five things to avoid:
- Do ensure that all required fields are completed accurately.
- Do provide clear and concise information about the incident.
- Do keep a copy of your completed form for your records.
- Do file your claim electronically through the NYC Comptroller's website.
- Do follow up if you do not receive confirmation of your claim.
- Don't forget to include your email address, as it is mandatory.
- Don't leave any required fields blank; this can delay your claim.
- Don't provide vague descriptions; be specific about the manner in which the claim arose.
- Don't submit your claim without verifying all information is correct.
- Don't include dollar signs or commas when entering the total amount claimed.
Misconceptions
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Misconception 1: The claim form can be filed in person at any office.
The New York Claim form must be filed electronically at the NYC Comptroller's website. In-person submissions are not accepted.
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Misconception 2: There is no deadline for filing a claim.
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 the claimant's rights.
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Misconception 3: Only the claimant can submit the form.
The form can be filed by the claimant or by an attorney on behalf of the claimant. If an attorney is involved, their information must be provided.
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Misconception 4: All fields on the form are optional.
Some fields are marked with an asterisk (*) and are required. Missing these can lead to delays or rejection of the claim.
Key takeaways
When filling out the New York Claim form, it's essential to pay attention to several key details to ensure your claim is processed smoothly. Here are six important takeaways:
- Filing Method: Claims can be filed electronically through the NYC Comptroller's website. Ensure you have access to the internet and follow the instructions provided on the site.
- Time Limit: 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.
- Required Information: Certain fields are mandatory. Make sure to fill in all required fields, including claimant's last name, first name, email address, date of incident, and location of incident.
- Claimant Details: If you are filing on behalf of someone else, provide their information, including their relationship to you. This is crucial for proper processing.
- Medical and Employment Information: Include details about medical treatment and any lost wages. This information helps establish the extent of damages and injuries claimed.
- Certification of Information: By signing the form, you certify that all information is true and correct. Be aware that providing false information can lead to serious legal consequences.
Taking the time to understand these points can greatly enhance the chances of a successful claim. Always double-check your entries for accuracy before submission.