Get Ny Nyc-compt-bla-pi1-b

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* Attorney is filing. On behalf of someone else. If on someone else s behalf please provide the following information* Last Name Attorney Information If claimant is represented by attorney Firm or Last Name First Name Address Relationship to the claimant City State Claimant Information Zip Code Tax ID Phone Email Address Retype Email NEW YORK The time and place where the claim arose Country Date of Incident USA Format MM/DD/YYYY Date of Birth Soc* Sec* Time of Incident Format HH MM AM/PM Location of Incident HICN Medicare Date of Death Occupation City Employee Yes Gender Male No NA Female Other Borough Denotes required fields. A Claimant OR an Attorney Email Address is required* Manner in which claim arose The items of damage or injuries claimed are include dollar amounts Witness 1 Information Medical Information 1st Treatment Date Hospital/Name Date Treated in Emergency Room Was claimant taken to hospital by an ambulance Employment Information If claiming lost wages Employer s Name Work Days Lost Amount Earned Weekly Treating Physician Information Complete if claim involves a NYC vehicle Owner of vehicle claimant was traveling in Non-City vehicle driver Insurance Information Insurance Company Name Make Model Year of Vehicle Plate VIN City vehicle information Policy Description of Driver Passenger Pedestrian Bicyclist Motorcyclist City Driver Last Total Amount Claimed Format Do not include or. required fields are entered Claimant Last Name Claimant First Name Claimant Email or Attorney Email Location of Incident 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. 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* Attorney is filing. On behalf of someone else. If on someone else s behalf please provide the following information* Last Name Attorney Information If claimant is represented by attorney Firm or Last Name First Name Address Relationship to the claimant City State Claimant Information Zip Code Tax ID Phone Email Address Retype Email NEW YORK The time and place where the claim arose Country Date of Incident USA Format MM/DD/YYYY Date of Birth Soc* Sec* Time of Incident Format HH MM AM/PM Location of Incident HICN Medicare Date of Death Occupation City Employee Yes Gender Male No NA Female Other Borough Denotes required fields. I am filing On behalf of myself* Attorney is filing. On behalf of someone else. If on someone else s behalf please provide the following information* Last Name Attorney Information If claimant is represented by attorney Firm or Last Name First Name Address Relationship to the claimant City State Claimant Information Zip Code Tax ID Phone Email Address Retype Email NEW YORK The time and place where the claim arose Country Date of Incident USA Format MM/DD/YYYY Date of Birth Soc* Sec* Time of Incident Format HH MM AM/PM Location of Incident HICN Medicare Date of Death Occupation City Employee Yes Gender Male No NA Female Other Borough Denotes required fields. A Claimant OR an Attorney Email Address is required* Manner in which claim arose The items of damage or injuries claimed are include dollar amounts Witness 1 Information Medical Information 1st Treatment Date Hospital/Name Date Treated in Emergency Room Was claimant taken to hospital by an ambulance Employment Information If claiming lost wages Employer s Name Work Days Lost Amount Earned Weekly Treating Physician Information Complete if claim involves a NYC vehicle Owner of vehicle claimant was traveling in Non-City vehicle driver Insurance Information Insurance Company Name Make Model Year of Vehicle Plate VIN City vehicle information Policy Description of Driver Passenger Pedestrian Bicyclist Motorcyclist City Driver Last Total Amount Claimed Format Do not include or. .