Free New York Claim Form
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The New York Claim Form is an essential document for individuals seeking compensation for personal injuries or damages caused by incidents involving the City of New York. This form, officially known as the NYC-COMPT-BLA-PI1-B, must be submitted electronically through the NYC Comptroller's website. It requires detailed information about the claimant, including personal details such as name, address, date of birth, and Social Security number. If someone is filing on behalf of another person, additional information about the relationship to the claimant is necessary. The form also captures critical details about the incident, including the date, time, and location, along with a description of how the claim arose. Claimants must specify the nature of their injuries and any damages incurred, including medical expenses and lost wages. Witness information is also collected to support the claim. Importantly, the form emphasizes the need for timely filing; if the claim remains unresolved for more than one year and 90 days from the incident date, legal action may be required to protect the claimant's rights. Completing the form accurately is crucial, as it includes mandatory fields that must be filled out to proceed with the claim.
Similar forms
The New York Claim form serves a specific purpose in filing personal injury claims. However, it shares similarities with several other legal documents. Below is a list of seven documents that are comparable to the New York Claim form, along with explanations of how they are similar.
- 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 detailed information about the incident, the parties involved, and the damages sought.
- Notice of Claim: Common in various jurisdictions, this document notifies a government entity of a claim against it. Similar to the New York Claim form, it often has strict deadlines and requires specific information about the incident and damages.
- Demand Letter: A demand letter is sent to the party responsible for the injury, detailing the claim and the amount sought. Both documents aim to outline the facts of the case and the damages, serving as a precursor to further legal action if necessary.
- Settlement Agreement: This document formalizes an agreement between parties to settle a claim without going to trial. It shares similarities with the New York Claim form in that it includes details about the incident and the agreed-upon compensation.
- Medical Release Form: Often required in personal injury cases, this form allows access to a claimant's medical records. Like the New York Claim form, it is critical for substantiating the injuries claimed and the treatment received.
- Insurance Claim Form: When filing a claim with an insurance company, this form collects information about the incident and damages. Similar to the New York Claim form, it requires specific details to assess the validity of the claim.
- Affidavit of Service: This document verifies that legal papers have been properly delivered to the involved parties. While it serves a different function, it is similar in that it is a formal document used in legal proceedings, ensuring that all parties are informed.
Form Preview
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.
Common mistakes
Filling out the New York Claim form can be a straightforward process, but many people make common mistakes that can delay their claims or lead to rejections. One frequent error is neglecting to complete all required fields. The form clearly marks certain fields with an asterisk (*), indicating that they must be filled out. If these fields are left blank, the claim will not be processed, and the claimant will need to resubmit the form, wasting valuable time.
Another mistake involves providing incorrect or incomplete contact information. Claimants often overlook the importance of accurate email addresses and phone numbers. If the contact information is wrong, the Comptroller’s office may not be able to reach the claimant for additional information or updates. This can lead to unnecessary delays in the processing of the claim.
Many people also fail to specify the manner in which the claim arose. This section is crucial as it provides context for the claim. Without a clear description, the claim may be deemed insufficient, requiring further clarification. Claimants should take the time to explain the circumstances of the incident thoroughly.
Additionally, some claimants forget to include all relevant documentation, such as medical records or witness information. This documentation supports the claim and provides evidence of the damages or injuries sustained. Without this information, the claim may lack credibility and could be dismissed or delayed.
Lastly, individuals often miscalculate the total amount claimed. The form specifies that the total should not include dollar signs or commas, but many still do. This simple formatting error can lead to confusion and may require corrections. It’s essential to double-check this figure and ensure it adheres to the form's guidelines before submission.
More About New York Claim
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What is the New York Claim Form?
The New York Claim Form is a document used to file a personal injury claim against the City of New York. It is essential for individuals seeking compensation for injuries or damages that occurred due to the actions of the city or its employees.
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How do I submit the claim form?
You can submit the claim form electronically through the NYC Comptroller's website. This online submission is the preferred method, as it ensures that your claim is processed efficiently. If you prefer, you can also submit a paper form by mailing it to the Office of the New York City Comptroller at 1 Centre Street, New York, NY 10007.
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What information is required on the claim form?
The form requires various details, including:
- Your personal information (name, address, contact details)
- The date, time, and location of the incident
- A description of how the claim arose
- Details about any injuries or damages, including medical treatment information
- Witness information, if applicable
Remember, fields marked with an asterisk (*) are mandatory.
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What happens if my claim is not resolved in time?
If your claim remains unresolved for one year and ninety days from the date of the incident, you must initiate legal action to preserve your rights. This is crucial because failing to do so may prevent you from receiving compensation.
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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. Make sure to include all required details to avoid delays in processing the claim.
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What if I have lost wages due to the incident?
If you are claiming lost wages, you must provide information about your employer, including their name and address. Additionally, you should indicate the number of workdays lost and the amount you typically earn weekly. This information will help support your claim for compensation.
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What should I include in the 'items of damage or injuries claimed' section?
In this section, you should detail the specific injuries or damages you are claiming. Include dollar amounts where applicable. This could encompass medical expenses, lost wages, and any other costs incurred as a result of the incident.
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What is the significance of the 'Total Amount Claimed' field?
The 'Total Amount Claimed' field is crucial because it summarizes the total compensation you are seeking. You can only fill this out after entering all required fields, such as your name, email, date and location of the incident, and the manner in which the claim arose. Ensure that you do not include symbols like "$" or "," when entering this amount.
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What are the consequences of providing false information on the claim form?
Providing false information on the claim form can lead to serious consequences. The law treats the willful making of any false statement as a criminal offense, which may result in criminal penalties and civil liabilities. It is vital to ensure that all information you provide is accurate and truthful.
Misconceptions
- Misconception 1: The New York Claim form can be submitted via mail.
- Misconception 2: You have unlimited time to file a claim.
- Misconception 3: Only the claimant can file the form.
- Misconception 4: All fields on the form are optional.
- Misconception 5: You do not need to provide any medical information.
- Misconception 6: Witness information is not necessary.
- Misconception 7: The total amount claimed can be entered at any time.
- Misconception 8: You can include dollar signs and commas in the total amount claimed.
- Misconception 9: Providing false information is not a serious issue.
This is incorrect. The form must be electronically filed at the NYC Comptroller's website.
Claims must be resolved within 1 year and 90 days from the date of occurrence. After this period, legal action is necessary to preserve your rights.
While the claimant can file on their own, an attorney can also file on behalf of the claimant, provided the necessary information is included.
Some fields are marked with an asterisk (*) and are required. Failing to complete these fields may result in a rejection of the claim.
Medical information is essential for claims involving injuries. The form requires details about treatment dates and hospital information.
Providing witness information can strengthen your claim. Including details about witnesses can help corroborate your account of the incident.
You can only enter the total amount claimed after filling out specific required fields, including claimant details and incident information.
The form specifically instructs you not to include "$" or "," when entering the total amount claimed.
Submitting false information can lead to criminal penalties and civil liabilities. Accuracy is crucial when completing the form.
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Key takeaways
When filling out the New York Claim form, keep these key takeaways in mind:
- File Electronically: Submit claims through the NYC Comptroller's website for efficient processing.
- Time Limit: If your claim isn't resolved within 1 year and 90 days from the incident, legal action is necessary to protect your rights.
- Required Fields: Ensure all required fields are completed, including claimant's name, email, and incident details.
- Claimant Information: Provide accurate information for the claimant or attorney, including contact details and relationship to the claimant.
- Incident Details: Clearly state the date, time, and location of the incident. Use the correct date format (MM/DD/YYYY).
- Damage Items: Specify the damages or injuries claimed, including dollar amounts where applicable.
- Witness Information: Include details for any witnesses to the incident, as this can support your claim.
- Certification: By signing, you certify that all information is accurate. False statements can lead to serious penalties.
New York Claim: Usage Guide
Filling out the New York Claim form requires careful attention to detail. Ensure that all necessary information is accurately provided. This process involves several steps, which must be followed to complete the form successfully.
- Determine if you are filing on your own behalf or on behalf of someone else. If filing for someone else, gather their personal information.
- Fill in the Claimant Information section. Include the claimant's last name, first name, relationship to the claimant, date of birth, social security number, and contact details.
- If applicable, provide Attorney Information. Include the attorney's firm name, address, and contact information.
- Document the time and place where the claim arose. Fill in the date and time of the incident, along with the location details.
- Describe how the claim arose. This section is mandatory, so ensure it is clear and concise.
- List the items of damage or injuries claimed. Include dollar amounts for each item.
- Complete the Medical Information section. Provide the first treatment date, the name of the hospital, and the address where treatment occurred.
- If applicable, provide information about witnesses. Include their names and contact details.
- For employment-related claims, fill in the Employer's Name, address, work days lost, and amount earned weekly.
- If the claim involves a NYC vehicle, complete the relevant sections regarding vehicle ownership and insurance information.
- Finally, enter the Total Amount Claimed, ensuring not to include any symbols like "$" or ",".
- Review all information for accuracy. Sign the form to certify that all details are true and correct.
Once you have completed the form, submit it electronically through the NYC Comptroller's website. Keep a copy for your records. If your claim is not resolved within 1 year and 90 days from the date of the incident, be prepared to take further legal action to protect your rights.