Article Guide
The New York Claim form, officially known as the Personal Injury Claim Form, is a critical document used to initiate claims for personal injuries sustained in incidents involving the City of New York. This form must be electronically filed through the New York City Comptroller's website, where specific details about the claim must be provided. Claimants have the option to file on their own behalf or on behalf of another individual, necessitating the inclusion of personal information such as names, relationships, and contact details. Essential fields include the date and time of the incident, location, and a description of how the claim arose. Claimants must also outline the damages or injuries incurred, including medical treatment details and any lost wages, if applicable. Witness information and insurance details for involved vehicles are additional components of the form. Importantly, claimants must be aware that if their claim remains unresolved for more than one year and 90 days, they will need to initiate legal action to protect their rights. The form emphasizes the accuracy of the information provided, as any false statements may lead to serious legal consequences.
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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 Specifications
| Fact Name | Description |
|---|---|
| Form Version | The New York Personal Injury Claim Form is identified as NYC-COMPT-BLA-PI1-B. |
| Filing Method | Claims must be electronically filed through the NYC Comptroller's website. |
| Legal Action Deadline | 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. |
| Governing Laws | This claim form is governed by New York State laws regarding personal injury claims. |
New York Claim: Usage Guidelines
Filling out the New York Claim form is a crucial step in the claims process. It is important to provide accurate and complete information to ensure your claim is properly processed. Follow the steps below to fill out the form correctly.
- Start by indicating whether you are filing on behalf of yourself or someone else. If filing for another person, provide their last name, first name, and your relationship to them.
- If an attorney is filing the claim, fill in the attorney's firm name, last name, first name, address, city, state, and any additional address information.
- Complete the claimant's information, including their last name, first name, address, city, state, zip code, country, date of birth, Social Security number, and Medicare number (if applicable).
- Provide the claimant's date of death (if applicable), phone number, email address, and occupation. Indicate if the claimant is a city employee and their gender.
- Document the time and place where the incident occurred. Include the date of the incident, time of the incident, and the location address, along with city, state, and borough.
- Describe how the claim arose in the specified section.
- List the items of damage or injuries claimed, including any dollar amounts associated with them.
- For medical information, enter the first treatment date, the hospital or treatment facility's name, and their address, city, state, and zip code. Also, provide the date treated in the emergency room.
- Include witness information for up to four witnesses, providing their last name, first name, address, city, state, and zip code for each.
- If applicable, indicate whether the claimant was taken to the hospital by ambulance.
- For employment information, include the employer's name, address, city, state, zip code, work days lost, and amount earned weekly.
- Provide treating physician information, including their last name, first name, address, city, state, and zip code.
- If the claim involves a NYC vehicle, complete the vehicle owner’s information and details of the non-city vehicle driver.
- Fill out the insurance information section, including the insurance company name, address, city, state, zip code, policy number, and phone number.
- Provide details about the non-city vehicle, including make, model, year, plate number, and VIN number. If applicable, provide the city vehicle information as well.
- Calculate and enter the total amount claimed. Ensure all required fields are completed before doing so.
- Finally, certify that all information provided is true and correct, understanding the potential penalties for false statements.
Your Questions, Answered
What is the New York Claim form?
The New York Claim form is a document used to file a personal injury claim with the New York City Comptroller's office. It is essential for individuals seeking compensation for injuries or damages incurred due to incidents involving the city or its employees.
How do I submit the New York Claim form?
The claim form must be submitted electronically via the NYC Comptroller's website. Ensure that all required fields are filled out completely to avoid delays in processing your claim.
What is the time limit for filing a claim?
You must file your claim within one year and 90 days from the date of the incident. If your claim is not resolved within this timeframe, you will need to initiate legal action to protect your rights.
What information is required on the form?
Essential information includes the claimant's name, contact details, date and location of the incident, description of how the claim arose, and details of any injuries or damages. Additionally, you must provide information about witnesses and any medical treatment received.
Can I file a claim on behalf of someone else?
Yes, you can file a claim on behalf of another person. You will need to provide the claimant's information, including their name and your relationship to them. This is important for establishing the legitimacy of the claim.
What if I have an attorney representing me?
If an attorney is filing the claim on your behalf, you must include their information on the form. This includes the attorney's name, firm, and contact details to ensure proper communication regarding the claim.
What should I do if I have lost wages due to my injury?
If you are claiming lost wages, you must provide your employer's information and details about the workdays lost. This information helps substantiate your claim for compensation related to lost income.
What happens if my claim is denied?
If your claim is denied, you will receive a notification explaining the reasons for the denial. You may have the option to appeal the decision or pursue legal action, depending on the circumstances surrounding your claim.
Is there a certification statement on the form?
Yes, the form includes a certification statement that you must sign. By signing, you affirm that all information provided is true and correct to the best of your knowledge. Misrepresentation may lead to legal consequences.
Common mistakes
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Neglecting Required Fields: Failing to fill out all fields marked with an asterisk (*) can lead to immediate rejection of your claim.
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Incorrect Date Formats: Using the wrong date format can result in confusion. Always use MM/DD/YYYY for dates.
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Missing Contact Information: Not providing a valid email address for the claimant or attorney may hinder communication.
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Omitting Details of the Incident: Failing to clearly describe the manner in which the claim arose can weaken your case.
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Inaccurate Medical Information: Providing incorrect details about medical treatment or failing to list all treatments can affect your claim.
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Not Including Witness Information: Forgetting to list witnesses or their contact details can limit your ability to support your claim.
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Claiming Without Evidence: Submitting a claim without sufficient evidence, such as medical bills or lost wage documentation, may lead to denial.
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Ignoring the Deadline: Not filing your claim within the required time frame of one year and 90 days can forfeit your rights.
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Inconsistent Information: Providing conflicting information in different sections of the form can raise red flags and delay processing.
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Failure to Sign and Certify: Not signing the form or failing to certify the accuracy of the information can invalidate your claim.
Documents used along the form
When filing a claim in New York, several additional forms and documents may accompany the New York Claim form. Each of these documents serves a specific purpose in supporting the claim process. Understanding these forms can help ensure that all necessary information is provided and that the claim is processed efficiently.
- Notice of Claim: This document formally notifies the city of the claim against it. It outlines the basis of the claim and the damages sought. Filing this notice is often a prerequisite for initiating a lawsuit.
- Medical Records: These documents provide evidence of the injuries sustained. They include treatment records, diagnoses, and any relevant medical history that supports the claim for damages.
- Witness Statements: Statements from individuals who witnessed the incident can bolster a claim. These documents capture the accounts of those who saw the event and can provide valuable context and support.
- Employment Records: If the claim includes lost wages, documentation from the claimant's employer is essential. This may include pay stubs, tax documents, and a statement detailing the workdays lost due to the incident.
- Insurance Information: This document outlines the insurance coverage related to the incident. It includes details such as the insurance company name, policy number, and contact information, which may be necessary for processing claims.
- Authorization for Release of Information: This form allows medical providers to share the claimant's medical records with the insurance company or legal representatives. It is crucial for facilitating the review of medical evidence related to the claim.
Each of these documents plays a vital role in the claims process. Ensuring that they are completed accurately and submitted on time can significantly affect the outcome of the claim. Being thorough and organized in this process is key to achieving a favorable resolution.
Similar forms
The New York Claim form shares similarities with several other legal documents. Here are five documents that have comparable features:
- Personal Injury Complaint: This document initiates a lawsuit and outlines the plaintiff's claims against the defendant. Like the New York Claim form, it requires details about the incident, the parties involved, and the nature of the injuries or damages.
- Notice of Claim: Similar to the New York Claim form, a Notice of Claim is often required before filing a lawsuit against a government entity. It includes information about the claimant, the incident, and the damages sought, ensuring that the government has notice of the potential claim.
- Demand Letter: A demand letter is sent to the responsible party before a lawsuit is filed. It outlines the facts of the case, the injuries sustained, and the compensation being sought. Like the New York Claim form, it serves to inform the other party of the claim and the damages being pursued.
- Medical Records Release Form: This form allows the claimant to authorize the release of their medical records. It is similar in that it collects personal information and details about the injuries sustained, which are crucial for substantiating the claim.
- Settlement Agreement: This document formalizes the terms of a settlement between the parties. While it comes later in the process, it also requires detailed information about the claim and the parties involved, similar to the New York Claim form.
Dos and Don'ts
Filing a claim can be a daunting task, especially when it comes to the New York Claim form. To help you navigate this process, here’s a list of essential dos and don’ts.
- Do ensure that all required fields are filled out completely. Missing information can delay your claim.
- Do provide accurate contact information. This is crucial for any follow-up regarding your claim.
- Do double-check your dates and details. Accuracy is key in establishing the legitimacy of your claim.
- Do keep a copy of your completed form for your records. This can be helpful for future reference.
- Don’t include any symbols like "$" or "," in the total amount claimed. Follow the formatting instructions carefully.
- Don’t submit your claim without reviewing it first. Errors can lead to complications or denials.
- Don’t forget to provide a valid email address. This is necessary for communication about your claim.
- Don’t rush through the process. Take your time to ensure everything is accurate and complete.
Misconceptions
- Filing can be done by anyone. Many believe that only the injured party can file a claim. In fact, a person can file on behalf of someone else, such as a family member, as long as the necessary information is provided.
- Claims must be filed in person. Some think that claims need to be submitted physically at an office. However, claims can be filed electronically through the NYC Comptroller's website.
- There is no time limit for filing a claim. A common misconception is that there is no urgency in filing. In reality, 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.
- All fields in the form are optional. Many people assume that they can skip any field they want. However, certain fields are marked with an asterisk (*) and are required for the claim to be valid.
- Only medical expenses can be claimed. Some believe that only medical costs are eligible for claims. In fact, individuals can claim various types of damages, including lost wages and other related expenses.
- Claims can be filed without supporting documents. There is a belief that a claim can be submitted without any evidence. However, providing supporting documents, such as medical records and witness information, strengthens the claim.
- Once filed, a claim cannot be changed. Many think that after submitting a claim, they cannot make any modifications. In truth, claimants can update their information or correct errors if necessary.
Key takeaways
Filling out the New York Claim form can be a straightforward process if you follow these key takeaways:
- Know where to file: Claims must be electronically submitted through the NYC Comptroller's website.
- Understand the time limits: If your claim is not resolved within 1 year and 90 days from the incident date, you must initiate legal action to protect your rights.
- Identify the claimant: Indicate whether you are filing on your own behalf or on behalf of someone else, and provide the necessary details if filing for another individual.
- Complete required fields: Certain fields are mandatory, such as the claimant's name, email address, and details about the incident. Ensure all required information is filled out to avoid delays.
- Document the incident: Clearly describe the manner in which the claim arose, including the date, time, and location of the incident.
- Detail damages: Specify the items of damage or injuries claimed, including any medical expenses and lost wages, along with dollar amounts where applicable.
- Provide accurate medical information: Include details about your treatment, such as the name of the hospital and the dates of treatment.
- Include witness information: List witnesses who can support your claim, providing their names and contact information.
- Verify your information: Before submitting, double-check all entries for accuracy. Any false statements can lead to serious legal consequences.
By following these takeaways, you can navigate the New York Claim form more effectively and ensure your claim is properly submitted.