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

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Form Version: NYC-COMPT-BLA-PI1-M: 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
A claim must be filed in person or by registered or certified mail within 90 days of the occurrence at the NYC
Comptroller's Office, located at 1 Centre Street, Room 1225, New York, NY 10007. The claim form must be
notarized. 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.
TYPE OR PRINT
Claimant Information
*Last Name:
*First Name:
Address:
Address 2:
City:
State:
Zip Code:
Country:
Date of Death:
Phone:
Email Address:
Occupation:
City Employee?
Yes No NA
Format: MM/DD/YYYYDate of Birth:
Soc. Sec. #
HICN:
(Medicare #)
Format: MM/DD/YYYY
Gender
Male Female Other
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:
Form Version: NYC-COMPT-BLA-PI1-M
* Denotes required field(s). Page 1 of 5
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:
New York City Comptroller
Brad Lander
Office of the New York City Comptroller
1 Centre Street
New York, NY 10007
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
*Manner in which
claim arose:
Attach extra sheet(s)
if more room is
needed.
The items of
damage or injuries
claimed are (include
dollar amounts):
Attach extra sheet(s)
if more room is
needed.
* Denotes required field(s). Page 2 of 5
New York City Comptroller
Brad Lander
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
Treating Physician Information
Last Name:
First Name:
Address:
Address 2:
City:
State:
Zip Code:
Office of the New York City Comptroller
1 Centre Street
New York, NY 10007
* Denotes required field(s). Page 3 of 5
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:
Witness 2 Information
Last Name:
First Name:
Address
Address 2:
City:
State:
Zip Code:
Witness 3 Information
Last Name:
First Name:
Address
Address 2:
City:
State:
Zip Code:
Witness 4 Information
Last Name:
First Name:
Address
Address 2:
City:
State:
Zip Code:
Witness 5 Information
Last Name:
First Name:
Address
Address 2:
City:
State:
Zip Code:
Witness 6 Information
Last Name:
First Name:
Address
Address 2:
City:
State:
Zip Code:
* Denotes required field(s). Page 4 of 5
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:
Format: Do not include "$" or ",".
* Denotes required field(s). Page 5 of 5
_______________________________________________________ __________________________________________________________
Date Signature of Claimant
State of New York
County of
I, _____________________________________________________, being duly sworn depose and say that I have read the foregoing
NOTICE OF CLAIM and know the contents thereof: that same is true to the best of my own knowledge, except as to the matter here stated
to be alleged upon information and belief, and as to those matters. I believe them to be true.
Sworn before me this day____________________________________
Signature of
Claimant______________________________________________ Signature of notary_________________________________________
New York City Comptroller
Brad Lander
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Form Version: NYC-COMPT-BLA-PI1-M: Personal Injury Claim Form (City of New York)

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Completed 8 March 2022

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