Fillable 1. General Municipal Law requires that all claims (City of Plattsburgh)

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1. General Municipal Law requires that all claims (City of Plattsburgh)

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NOTE:
1. General Municipal Law requires that all claims against the City of Plattsburgh be presented
WITHIN NINETY (90) DAYS OF THE DATE OF THE DAMAGE, INJURY OR LOSS.
2. This Notice of Claim must be served on the City Clerk's Office, 41 City Hall Place,
Plattsburgh, NY 12901, either by personal service or certified or registered mail. The City of its
representative may request additional information regarding this claim.
3. Call (518) 563-7702 if you have questions regarding this form.
4. Attach additional pages/items as you deem necessary.
CLAIMANT:
Name: _______________________________________________________________________
Address: ______________________________________________________________________
Home Phone: __________________________________________________________________
Daytime/Business Phone: ________________________________________________________
Legal Representative (if other than Claimant): ________________________________________
Representative Address/Phone: ____________________________________________________
CLAIM: (DAMAGE/ INJURY/ LOSS INFORMATION)
Date/time:__________________________________________
Location:___________________________________________
Brief Description of damage/injury/loss:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
IF INCIDENT WAS REPORTED TO A CITY AGENCY:
Agency Name: ________________________________________
To Whom: ____________________________________________
Date/time: ____________________________________________
WITNESSES: (NAME, ADDRESS, PHONE)
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
CLAIM FOR DAMAGE/INJURY/LOSS AND BASIS OF VALUE:
______________________________________________________________________________
______________________________________________________________________________
______________________________________________________________________________
(attach appraisal, estimate, receipts, etc. as necessary; the City may seek independent
verification)
CLAIMANT INSURANCE INFORMATION:
Agent and/or Company: ________________________________
Policy #:____________________________________________
Phone: ______________________________________________
NOTICE OF CLAIMS
NOTE: Presentation for allowance or payment of a false or fraudulent claim with the intent to
commit a fraud is crime punishable as a felony under New York Law.
I HAVE READ THE FOREGOING NOTICE OF CLAIM AND SAID CLAIM AND
INFORMATION IS TRUE AND COMPLETE TO THE BEST OF MY KNOWLEDGE
AND BELIEF:
Signature: ________________________________________________________
State of New York)
) ss:
County of Clinton )
Sworn to before me this ______
Day of __________, _________
__________________________
Notary Public
NOTICE OF CLAIMS
__________________________________________________________________________________________________
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Completed 21 January 2021

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