Fillable Vehicular Property Damage Claim Form (City of New York)

Fill Online, Printable, Fillable, Blank Vehicular Property Damage Claim Form (City of New York) Form

Use Fill to complete blank online CITY OF NEW YORK pdf forms for free. Once completed you can sign your fillable form or send for signing. All forms are printable and downloadable.

Vehicular Property Damage Claim Form (City of New York)

On average this form takes 50 minutes to complete

The Vehicular Property Damage Claim Form (City of New York) form is 6 pages long and contains:

  • 1 signature
  • 52 check-boxes
  • 173 other fields

Country of origin: US
File type: PDF

U.S.A. forms for City of New York

BROWSE CITY OF NEW YORK FORMS

Related forms
Fill has a huge library of thousands of forms all set up to be filled in easily and signed.
Fill in your chosen form
Sign the form using our drawing tool
Send to someone else to fill in and sign.
find another form
 
Office of the New York City Comptroller
1 Centre Street
New York, NY 10007
Vehicular Property Damage 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-PD3-D3
* Denotes required fields.
A Claimant OR an Attorney Email Address is required.
Gender
Male Female Other
Relationship to
the claimant:
First Name:
Last Name:
On behalf of myself.
On behalf of someone else. If on someone else's
behalf, please provide the following information.
Attorney is filing.
I am filing:
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
The items of
damage claimed
are (include dollar
amounts):
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:
Police Information
Police Officer Last
Name:
Police Officer First
Name:
Shield Number:
Precinct:
Report Number:
Do you have a copy of the Police Report?
Yes No
AUTHORIZATION TO INSPECT AND APPRAISE YOUR VEHICLE'S
DAMAGE
You must complete the following. By completing the
following you are allowing us to inspect and appraise your
vehicle.
Make, Model, Year
of Vehicle:
Plate #:
VIN Number:
Mileage
Location where the
vehicle can be seen:
Phone:
New York City Comptroller
Brad Lander
Office of the New York City Comptroller
1 Centre Street
New York, NY 10007
Vehicle information
Owner Last
Name
Owner First
Name
Make, Model,
Year of Vehicle:
Mileage
Color
Plate #:
Driver information if different than claimant
Last Name:
First Name:
Address:
Address 2:
City:
State:
Zip Code:
Country:
Phone:
Email Address:
Retype email
Address:
Occupation:
City Employee?
Yes No NA
Gender
Male Female Other
Insurance Information
Do you have collision insurance?
Yes No
Did you report your accident to your insurance
company?
Yes No
Were you paid by your insurance company?
Yes No
Deductible Amount:
Insurance Company
Name:
Address:
Address 2:
City:
State:
Zip Code:
Policy #:
Phone #:
Agent Name:
Tow Claims
Format: MM/DD/YYYY
Tow Date:
Tow Time:
Location vehicle
was picked up at
Receipt Number:
Voucher Number:
NYC vehicle information
Last Name:
First Name:
Address
Address 2:
City:
State:
Zip Code:
Vehicle Type:
Plate #:
Towed Away?
Yes No
Is payment pending?
Yes No
Was vehicle released or towed?
Released Towed NA
Format: MM/DD/YYYY
Redemption Date:
Time of tow:
Location of tow:
From:
To:
Towed by Sheriff or Marshall?
Sheriff Marshall NA
District Attorney
Release Number:
Format: HH:MM AM/PM
Format: HH:MM AM/PM
New York City Comptroller
Brad Lander
Office of the New York City Comptroller
1 Centre Street
New York, NY 10007
Total Amount
Claimed:
The Total Amount Claimed can only be entered once the following
required fields are entered: Claimant Last and First Name,Claimant
Address,City,State,Zip Code, Country, Claimant or Attorney Email,
Date of Incident, Location of Incident (including State), and Manner
in which claim arose.
Accident Diagram: Choose one of these diagrams if it
describes the accident.
1 2 3
4 5 6
7 8 9
None of these diagrams describes the accident.
Conditions and description of accident/incident location
Choose the actions of the vehicle before the accident:
Yours NYC
Going straight ahead
Making a right turn
Making a left turn
Making a U-turn
Starting from a parked position
Starting in traffic
Slowing or stopping
Stopped in traffic
Entered a parked position
Parked
Avoiding object in roadway
Overtaking
Merging
Backing
Changing lanes
Other
Roadway surface conditions - Check all that apply
Dry
Wet
MuddyConstruction (man-made cut)
Potholes (wear & tear condition)
Snow or ice
Slush
Other
Traffic Control
None
Red - Green - Yellow
Not WorkingFlashing
Person directing traffic
Red - Green
Stop Sign
Describe damage to
your vehicle. Include:
What caused the
accident?
Was the location
under repair?
Were the repairs
recently completed?
Does the defect
appear to be man-
made?
Name of Construction
Company?
Was the defect next to
a manhole? If yes,
please specify which
utility by name.
What are the
measurements of the
defect? (length, width,
depth)
Weather Conditions
Clear Rain Fog/Smoke/Smog
Sleet/Hail/Freezing/Rain/Snow Other
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
Download
Save PDF to desktop
Email
Email completed PDF
Send for Signing
Email for others to sign
Print
Print document
Choose a Field
Click on a field and
select the person that should complete it
Want to add a signature?
You can add a signature field
and assign it to someone else
to sign
Choose a Field
Click on a field and
select the person that should complete it

Vehicular Property Damage Claim Form (City of New York)

This document is locked as it has been sent for signing.

You have successfully completed this document.

Other parties need to complete fields in the document. You will recieve an email notification when the document has been completed by all parties.

This document has been signed by all parties.

Completed 4 February 2022

Message

View Audit Log
Print With Audit Log
Duplicate Document