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In navigating the complexities of the legal landscape following personal injuries, the New York Claim form emerges as a pivotal document, particularly under the jurisdiction of the Office of the New York City Comptroller. This form, designated as NYC-COMPT-BLA-PI1-B, serves a crucial role in initiating the claim process for individuals who have encountered personal injuries within the city’s precincts. It offers a structured path for claimants to provide comprehensive details about the incident at hand, be it filed personally or on someone else’s behalf. The inclusion of sections for attorney information, when the claimant is represented, adds another layer of procedural specificity, underscoring the form’s adaptability to varying circumstances. Claimants are required to furnish details ranging from personal identification to intricate descriptions of the incident, including the time, location, and nature of the claim, alongside the injuries or damages incurred, expressed with requested dollar amounts for clarity and precision. Detailed medical, employment, and witness information sections ensure a thorough conveyance of the event’s impact and the resultant losses, further supported by sections dedicated to insurance and involved vehicles, highlighting the form’s encompassing nature. Moreover, the strict timeframe for filing extensions—beyond which legal rights must be pursued through litigation—emphasizes the importance of timeliness and accuracy in submission. The form concludes with a stern reminder of the legal implications of falsifying information, reflecting its gravity and the meticulous attention required for its completion. Through its comprehensive structure, the New York Claim form stands as a testament to the procedural rigor involved in claiming for personal injuries, navigating claimants through their pursuit of justice and compensation.

New York Claim Sample

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

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

 

 

 

 

 

 

*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:

 

 

 

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.

⇩ New York Claim

File Overview

Fact Name Description
Form Usage The Personal Injury Claim Form is used to file a claim for personal injury with the Office of the New York City Comptroller.
Electronic Filing Claims must be electronically filed at the NYC Comptroller's Website.
Statute of Limitations If a claim is not resolved within 1 year and 90 days from the date of the incident, legal action must be started to preserve the claimant's rights.
Required Fields Claims must include specific required fields such as Claimant's Last Name, First Name, Email Address (or Attorney's Email), Date of Incident, Location of Incident, and the Manner in which the claim arose.
Governing Law The process and requirements for filing personal injury claims are governed by New York State laws and regulations specific to claims against the City of New York.

New York Claim: Usage Guidelines

After someone incurs a personal injury that they believe involves the responsibility of New York City, filling out the New York Claim form is crucial for reporting the occurrence. This form is key to officially notifying the Office of the New York City Comptroller about the incident, enabling a proper review of the case. It's important to complete the form carefully, ensuring all information is accurate and submitted within the specified timeline. Below are detailed steps to guide through the process of filling out the form.

  1. Visit the NYC Comptroller's Website to access the Personal Injury Claim Form.
  2. Select your filing status: whether you're filing on behalf of yourself or someone else. If filing on someone else's behalf, enter their Last Name, First Name, and Relationship to the claimant.
  3. If an attorney is representing the claimant, fill in the Attorney Information section with the Firm or Attorney's Last Name, First Name, Address, and contact details.
  4. Under Claimant Information, fill in the claimant's Last Name, First Name, Address, City, State, Zip Code, Country, Date of Birth, Social Security Number or Medicare Number (HICN), Date of Death (if applicable), Phone Number, Email Address (and confirmation), Occupation, City Employee status, and Gender.
  5. Enter the Date and Time of the Incident, along with the exact Location of Incident including Address, City, State, and Borough.
  6. Describe the Manner in which the claim arose, detailing the circumstances.
  7. List the items of damage or injuries claimed, including any dollar amounts. Fill in the Medical Information section with the Date of First Treatment, Hospital Name, Address, and the Date Treated in the Emergency Room.
  8. Witness Information: If there are witnesses, provide their Last Name, First Name, and Address details for up to four witnesses.
  9. If the claim involves lost wages, complete the Employment Information section with the Employer's Name, Address, Work Days Lost, and Amount Earned Weekly.
  10. Provide Treating Physician Information with the Last Name, First Name, and Address.
  11. If the claim involves a New York City vehicle, fill out the relevant section with Owner or Non-City vehicle driver information and Insurance Information.
  12. For Non-City vehicles involved, input Make, Model, Year of Vehicle, Plate #, VIN #. For City vehicles, include Plate #, City Driver Last Name, and Description of Passenger or Driver First Name depending on the situation.
  13. Enter the Total Amount Claimed without using "$" or ",". Ensure this is done after filling out all required fields: Claimant Last Name, Claimant First Name, Claimant Email or Attorney Email, Date of Incident, and Location of Incident.
  14. Finish by certifying that all information contained in the notice is true and correct by checking the appropriate box or providing a signature if required.
  15. Submit the completed form electronically on the NYC Comptroller's Website or as directed on the form if a physical submission is necessary.

Following submission, the claim will undergo a review process by the Office of the New York City Comptroller. The claimant or their attorney will be contacted regarding any further requirements or to provide updates on the status of the claim. It's important to respond promptly to any correspondence or requests for additional information to ensure the review process moves forward efficiently.

FAQ

  1. What is the New York Claim Form?

    The New York Claim Form, specifically referred to as NYC-COMPT-BLA-PI1-B, is a document provided by the Office of the New York City Comptroller. It is designed for individuals wishing to file a personal injury claim against the city. The form facilitates the reporting of injuries or damages that occurred within the city's jurisdiction, allowing claimants to seek compensation.

  2. How can I file this claim electronically?

    To file a claim electronically, it must be submitted through the NYC Comptroller's Website. This process streamlines the submission of personal injury claims, making it easier for residents and attorneys to navigate the claims process against New York City efficiently.

  3. What is the deadline to file a claim or start legal action?

    A claim must be resolved within 1 year and 90 days from the date of the occurrence. If the claim is not resolved within this timeframe, legal action must be initiated to preserve the rights of the claimant. This strict timeline emphasizes the importance of timely action following an incident.

  4. Who can file a claim?

    A claim can be filed by the individual who suffered damages or injuries themselves, on behalf of someone else (where information such as the last name, first name, and the relationship to the claimant should be provided), or by an attorney representing the claimant. When an attorney files on behalf of a claimant, detailed attorney information, including firm name and contact details, must be included.

  5. What information is required to complete the form?

    The form requires detailed claimant information, including personal details, the specific time and place where the incident occurred, the manner in which the claim arose, and a list of damages or injuries claimed, potentially including dollar amounts. Additionally, if applicable, medical treatment, witness information, employment information for lost wages claims, and vehicle information in cases involving vehicles will be necessary.

  6. Is an email address necessary to file this claim?

    Yes, providing an email address is mandatory for the submission of this claim. The form specifies that either a claimant or an attorney email address is required to proceed with filing. This requirement ensures efficient communication between the Comptroller’s Office and the person filing the claim.

  7. What are the consequences of providing false information on this form?

    Providing false information on the New York Claim Form is taken very seriously. The claimant understands that the willful making of any false statement of material fact in this form will subject them to criminal penalties and civil liabilities. This underscores the imperative of accurate and truthful information throughout the claim process.

Common mistakes

Filling out the New York Claim Form accurately is crucial for ensuring your personal injury claim is processed efficiently and effectively. However, it's easy to make errors that can delay your claim or impact its success. Here are seven common mistakes to avoid:

  1. Missing Deadlines: Many people aren't aware of the strict timeline that the form stipulates. Claims must be filed within 1 year and 90 days from the date of the incident. Missing this deadline can result in losing the right to file a claim.
  2. Incorrect Information: Sometimes, claimants provide incorrect information concerning their personal details or about the incident. Double-check everything, especially essential fields like Social Security numbers, dates of birth, and the date, time, and location of the incident.
  3. Omitting Email Verification: A common oversight is neglecting to retype the email address for verification. Since an email address for either the claimant or attorney is mandatory, ensuring it's entered correctly twice is vital for communication.
  4. Incomplete Incident Description: Providing a vague or incomplete description of how the claim arose is another mistake. It's important to offer a clear and detailed account of the events leading to the injury.
  5. Leaving out Witness Information: Witnesses can significantly support your claim. Failing to include witness information, when available, might weaken your case.
  6. Not Specifying Lost Wages Clearly: If you're claiming lost wages, it's crucial to specify the amount of workdays lost and your weekly earnings accurately. This information helps in calculating the compensation due for lost wages.
  7. Misunderstanding the 'Total Amount Claimed' Section: Some people either leave this blank or enter incorrect figures because they're unsure of what constitutes the total amount. Remember to include all damages such as medical expenses, lost wages, and any other related costs.

By avoiding these mistakes, you can ensure your New York Claim Form is filled out correctly, which will facilitate a smoother claims process. Remember to provide as much detail as possible and double-check all your information before submission. Understanding and carefully completing the form is the first step toward receiving the compensation you may be entitled to.

Documents used along the form

When dealing with a New York Claim form, particularly for personal injuries as outlined by the Office of the New York City Comptroller, it's important to understand and gather other documents that often accompany this form. These documents play a critical role in substantiating the claim, providing detailed evidence, and ensuring that the process goes smoothly for all parties involved. From medical records to witness statements, each document has its unique importance in the claims process.

  • Medical Records: These are comprehensive reports from healthcare providers documenting the claimant's injuries, treatment received, and the prognosis. Medical records serve as concrete evidence of the physical damages sustained due to the incident and are crucial for calculating the compensation sought.
  • Police Report: If law enforcement was involved, a police report would be generated. This report provides an official account of the incident, including details from the scene, statements from involved parties, and sometimes, the responding officer's assessment of fault. It is valuable for corroborating the claimant's account of the event.
  • Witness Statements: Statements from individuals who witnessed the incident can significantly strengthen a claim. These firsthand accounts offer additional perspectives and can help clarify the events that led to the injury, supporting the claimant's version of events.
  • Photographic Evidence: Photos or videos from the scene of the incident can serve as powerful visual evidence, helping to establish the context and severity of the incident. This might include pictures of the injury, damage to property, or any hazards that contributed to the incident.

Collecting and presenting these documents alongside the New York Claim form can significantly impact the outcome of the claim process. Not only do they provide a comprehensive view of the incident and its aftermath, but they also work to validate the claimant's experience and the extent of damages or injuries sustained. Understanding the role each document plays and ensuring they are accurately and thoroughly prepared is essential for anyone navigating this process.

Similar forms

The New York Claim form bears resemblance to a traditional personal injury complaint form used in civil litigation. A personal injury complaint form initiates legal action in court by an individual who alleges harm due to another party's negligence or intentional act. Both documents require detailed information about the claimant, the incident, and the alleged damages. They outline the nature of the injuries, the time and location of the incident, and demand compensation for losses. Importantly, just as the New York Claim form mandates, a personal injury complaint form must be filed within a specific statutory period to preserve the claimant's legal rights.

Comparably, the New York Claim form shares similarities with workers' compensation claim forms. These are filed by employees who suffer job-related injuries or illnesses. Like the New York Claim form, workers' compensation claims require detailed information about the claimant, including their employment information, the circumstances surrounding the incident, and the extent of the injuries. Both forms play a critical role in the process of seeking compensation, although they serve different legal pathways—workers' compensation claims typically proceed through administrative systems rather than courts.

Another closely related document is the auto insurance claim form, which is used following a motor vehicle accident. Drivers involved in an accident must provide their insurance companies with detailed information similar to what is requested on the New York Claim form, such as personal, vehicle, and accident details, and the extent of any injuries or damages. Both forms are essential for the initiation of a claim process aimed at recovering damages. The key difference lies in the nature of liability and compensation mechanisms, with insurance claims typically resolved through contractual obligations under the policy terms.

Additionally, the New York Claim form aligns with property damage claim forms used to report and seek compensation for property damage. Property owners must provide detailed information about the damage, how it occurred, and the estimated repair costs—paralleling the requirements on the New York Claim form concerning incident details, damages, and injuries claimed. Both documents are foundational in the pursuit of compensation, whether the claim involves personal injury or property loss, and require prompt and precise completion to effectively process the claim.

Dos and Don'ts

When completing the New York Claim Form, it is essential to adhere to a certain set of guidelines to ensure the process is conducted accurately and efficiently. Below are key dos and don’ts to guide you through this procedure.

Dos:

  1. Ensure all required fields marked with an asterisk (*) are completed to avoid delays in the processing of your claim.

  2. Verify the accuracy of the email address provided, as either the claimant or the attorney's email address is mandatory for communication regarding your claim.

  3. Include detailed information about the time and location of the incident to establish a clear context for your claim.

  4. Document all items of damage or injuries claimed, and where possible, assign dollar amounts to them to provide clear expectations for compensation.

  5. Seek the assistance of witnesses by including their information on the form, as their testimonies can significantly support your claim.

  6. For claims involving lost wages, ensure you provide comprehensive employment information along with details about work days lost and amount earned weekly.

  7. Review all entered information for accuracy before submission to ensure the claim can be processed smoothly.

Don’ts:

  1. Do not omit any required information, as incomplete forms may be rejected or result in unnecessary delays.

  2. Avoid guessing dates or times. Ensure all provided dates and times, such as the date and time of the incident, are as accurate as possible.

  3. Do not include irrelevant or unnecessary details in the manner in which the claim arose section to prevent confusion and expedite review time.

  4. Avoid providing incomplete medical or treatment information. Full details about the first treatment date, hospital, and treating physician support the validation of your injuries.

  5. Do not leave the total amount claimed section blank. Complete it once all other required fields that influence this amount are filled out.

  6. Avoid signing the form without reviewing all entered information for veracity, as providing false information can lead to criminal and civil penalties.

  7. Do not disregard the guidelines for electronically filed claims if you choose to submit your form online, as these may have specific instructions or requirements.

Misconceptions

Many people have misconceptions about the New York Claim form, which can lead to mistakes or confusion when submitting a claim. It's important to clear up these misunderstandings to ensure submissions are accurate and meet all necessary legal requirements. Here's a look at some common misconceptions:

  • All sections must be filled out by the claimant directly. This is not necessarily true. An attorney can file on behalf of a claimant, which is especially common in cases where the claimant may not be able to complete the form due to injuries or legal complexities. The form provides specific sections for attorney information, indicating that representation is permitted and sometimes advised.

  • Claims can only be submitted in person or by mail. The form states that electronically filed claims are accepted through the NYC Comptroller's Website. This allows for faster submission and is convenient for those who cannot easily visit the office or send mail.

  • You have an indefinite amount of time to file a claim. There's a specific timeframe stipulated on the form — 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. This period is crucial as missing the deadline can result in the loss of the right to claim.

  • Claims are only for physical injuries. While the form is titled Personal Injury Claim Form, its sections also allow for the reporting of property damage and other losses (e.g., lost wages). This means claims can cover a broad range of issues, not just physical injuries.

  • A claimant's information is all that's needed. The form requires detailed information beyond just that of the claimant, including witness information, treating physician details, and employment information if lost wages are being claimed. This comprehensive data supports a thorough investigation and resolution of the claim.

  • The Total Amount Claimed field must be filled with an exact dollar amount initially. The form clarifies that the total amount claimed can only be entered once certain required fields are completed, emphasizing that understanding the full scope of the claim is necessary before determining the total amount of compensation sought. It's essential to assess all damages meticulously before summing up the claim.

Understanding these nuances is critical for anyone looking to file a claim with the Office of the New York City Comptroller. Clearing up these misconceptions can help streamline the process and avoid unnecessary delays or rejections due to incorrect or incomplete information.

Key takeaways

Filling out and using the New York Claim Form, a tool designed for individuals to navigate the claims process in New York, involves several crucial steps and considerations. This document, utilized for submitting personal injury claims among others, underscores the necessity of precise and truthful information submission to the Office of the New York City Comptroller. Below are key points to remember when dealing with this form:

  • Electronically Filed Claims: For an enhanced and expedited process, claims can and should be filed through the NYC Comptroller's Website. This mode of submission not only streamlines the handling of the form but also supports a more eco-friendly approach by reducing paper use.
  • Time Sensitivity: The claimant has a strict deadline of 1 year and 90 days from the date of the incident to resolve the claim. Failure to reach a resolution within this timeframe necessitates initiating legal action to preserve the claimant's rights, highlighting the importance of timely action in the claims process.
  • Representation: It’s permissible for the claim itself to be filed either by the individual directly affected or on their behalf by another party. This flexibility accommodates varying circumstances, including instances where the claimant may be unable to file due to the severity of injuries or age. Furthermore, representation by an attorney is accounted for, requiring detailed attorney and law firm information to ensure proper communication and handling of the claim.
  • Required Fields: The form mandates the completion of several critical fields to process the claim effectively. These include claimant's personal information, details about the incident (such as time, date, and location), as well as a detailed account of the manner in which the claim arose. This level of detail is crucial for a thorough evaluation of the claim.
  • Medical and Employment Documentation: Offering detailed medical information—including treatments received and the healthcare provider's details—alongside any claims for lost wages due to work absence, underpins the claim with verifiable evidence. The inclusion of this information supports the substantiation of the claim’s validity and the assessment of the compensation amount.
  • Witness and Incident Information: The form provides space for including witness information, which can play a pivotal role in substantiating the claimant's account of the incident. For accidents involving vehicles, detailed information concerning the vehicles, including insurance details, is required. Such comprehensive data collection facilitates a more accurate and fair evaluation of the claim.

Adherence to these key aspects when filling out the New York Claim Form not only ensures that the submission is succinct and comprehensive but also significantly influences the efficiency and outcome of the claims process. Understanding and correctly implementing these steps is fundamental to navigating legal procedures related to claims in New York.

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