Download New York Claim Template in PDF

• Personal Injury Complaint Form: Similar to the New York Claim form, this document is used to initiate a personal injury lawsuit. It requires claimant information, details of the incident, and the nature of injuries sustained.

• Notice of Claim: This document serves as a formal notification to a government entity about a claim for damages. Like the New York Claim form, it includes details about the claimant and the circumstances surrounding the claim.

• Medical Release Form: This form allows the release of medical records related to the injury. It parallels the New York Claim form by requiring medical information and treatment details.

• Employment Verification Form: Often required in personal injury cases, this document verifies lost wages and employment status. It is similar in that it collects employment information and details related to the claimant's work history.

• Accident Report: This document, typically filed with law enforcement, details the circumstances of an accident. It shares similarities with the New York Claim form in documenting the time, place, and manner of the incident.

• Insurance Claim Form: Used to file a claim with an insurance company, this form requests similar information about the incident and the claimant’s injuries, akin to the requirements of the New York Claim form.

• Witness Statement Form: This document collects testimonies from witnesses regarding an incident. It is comparable to the New York Claim form, which also requests witness information to support the claim.

• Subrogation Claim Form: This form is used by insurance companies to recover costs from third parties. It is similar in that it requires details about the incident and damages, much like the New York Claim form.

• Release of Liability Form: This document is often signed to waive rights to future claims. It parallels the New York Claim form by addressing the potential for damages related to an incident.

• Settlement Agreement: This document outlines the terms of a settlement between parties. It is similar in that it involves the resolution of a claim and may reference the damages outlined in the New York Claim form.

Guide to Filling Out New York Claim

Filling out the New York Claim form requires careful attention to detail. This process involves providing personal information, details about the incident, and any damages claimed. Follow these steps to ensure that your form is completed accurately.

1. Begin by indicating whether you are filing on your own behalf or on behalf of someone else.
2. If filing for someone else, fill in their last name, first name, and your relationship to them.
3. If an attorney is filing, provide their firm name, last name, first name, and contact address.
4. Complete the claimant's information, including last name, first name, address, city, state, zip code, country, date of birth, Social Security number, and Medicare number if applicable.
5. Provide the claimant's phone number, email address, and occupation. Indicate if the claimant is a city employee and their gender.
6. Fill in the date and time of the incident, ensuring to use the correct formats.
7. Specify the location of the incident by providing the address, city, state, and borough.
8. Describe how the claim arose in the designated section.
9. List the items of damage or injuries claimed, including dollar amounts.
10. For medical information, enter the first treatment date, hospital name, and address, including city, state, and zip code.
11. Indicate if the claimant was taken to the hospital by ambulance.
12. If claiming lost wages, provide the employer's name, address, and the number of workdays lost, along with the weekly earnings amount.
13. Include information about the treating physician, providing their name and address.
14. For any witnesses, fill in their names and addresses as required.
15. If the claim involves a NYC vehicle, provide details about the owner of the vehicle and the driver of any non-city vehicle involved.
16. Fill in the insurance information, including the insurance company name, address, policy number, and phone number.
17. For vehicle information, list the make, model, year, plate number, and VIN for both city and non-city vehicles.
18. Finally, calculate the total amount claimed, ensuring not to include "$" or "," in the entry.
19. Certify that all information provided is true and correct, understanding the implications of any false statements.