Fillable Form Version: NYC-COMPT-BLA-PI1-D7: Personal Injury Claim Form (City of New York)

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Form Version: NYC-COMPT-BLA-PI1-D7: Personal Injury Claim Form (City of New York)

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Office of the New York City Comptroller
1 Centre Street
New York, NY 10007
Personal Injury Claim Form
Electronically filed claims must be filed within 90 days of the occurrence using the Office of the NYC Comptroller's
website. If the claim is not resolved within one (1) year and 90 days of the occurrence, you must start a separate legal
action in a court of law before the expiration of this time period to preserve your rights.
Claimant Information
*Last Name:
*First Name:
*Address:
Address 2:
*City:
*State:
*Zip Code:
*Country:
Date of Death:
Phone:
*Email Address:
*Retype Email
Address:
Occupation:
City Employee?
Yes No NA
Format: MM/DD/YYYYDate of Birth:
Soc. Sec. #
HICN:
(Medicare #)
Format: MM/DD/YYYY
Attorney Information (If claimant is represented by attorney)
Firm or Last Name:
Firm or First Name:
Address:
Address 2:
City:
State:
Zip Code:
Tax ID:
Phone #:
*Email Address:
*Retype Email
Address:
Form Version: NYC-COMPT-BLA-PI1-D7
* Denotes required fields. A Claimant OR an Attorney Email Address is required.
Gender
Male Female Other
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.
Last Name:
First Name:
Relationship to
the claimant:
The time and place where the claim arose
*Date of Incident:
Time of Incident:
*Location of
Incident:
Address:
Address 2:
City:
*State:
Borough:
Format: MM/DD/YYYY
Format: HH:MM AM/PM
New York City Comptroller
Brad Lander
NEW YORK
USA
NEW YORK
click to sign
signature
click to edit
Office of the New York City Comptroller
1 Centre Street
New York, NY 10007
*Manner in which
claim arose:
* Denotes required field.
New York City Comptroller
Brad Lander
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):
New York City Comptroller
Brad Lander
Office of the New York City Comptroller
1 Centre Street
New York, NY 10007
Witness 1 Information
Last Name:
First Name:
Address
Address 2:
City:
State:
Zip Code: Phone:
Witness 2 Information
Last Name:
First Name:
Address
Address 2:
City:
State:
Zip Code: Phone:
Witness 3 Information
Last Name:
First Name:
Address
Address 2:
City:
State:
Zip Code: Phone:
Witness 4 Information
Last Name:
First Name:
Address
Address 2:
City:
State:
Zip Code: Phone:
Treating Physician Information
Last Name:
First Name:
Address:
Address 2:
City:
State:
Zip Code:
Employment Information (If claiming lost wages)
Employer's Name:
Address
Address 2:
City:
State:
Zip Code:
Work Days Lost:
Amount Earned
Weekly:
Medical Information
1st Treatment Date:
Hospital/Name:
Address:
Address 2:
City:
State:
Zip Code:
Date Treated in
Emergency Room:
Was claimant taken to hospital by
an ambulance?
Yes No NA
Format: MM/DD/YYYY
Format: MM/DD/YYYY
New York City Comptroller
Brad Lander
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:
Insurance Information
Insurance Company
Name:
Address
Address 2:
City:
State:
Zip Code:
Policy #:
Phone #:
Description of
claimant:
Driver Passenger
Pedestrian Bicyclist
Motorcyclist Other
Non-City vehicle driver
Last Name:
First Name:
Address
Address 2:
City:
State:
Zip Code:
Non-City vehicle information
Make, Model, Year
of Vehicle:
Plate #:
VIN #:
City vehicle information
Plate #:
City Driver Last
Name:
City Driver First
Name:
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 Address,City,State,Zip Code, and Country
Claimant Email or Attorney Email
Date of Incident
Location of Incident (including State)
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 City Comptroller
Brad Lander
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Form Version: NYC-COMPT-BLA-PI1-D7: Personal Injury Claim Form (City of New York)

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Completed 8 March 2022

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