Nys Department Of Transportation Small Claims Form Page 3
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4New York State Department of Transportation
Small Claim Form
Please type or print legibly using ink. Answer all questions in as much detail as possible. Attach
additional information if necessary.
1. Owner Information:
Name:
Address:
Telephone Number
: Day:
Evening:
(including area code)
If applicable,
Vehicle Make:
Model:
Year:
Color:
Plate:
Mileage:
2. Insurance Payment:
Have you received, or expect to receive, any payment from your insurance carrier for this
claim?
yes
no
(check one)
If the answer is “yes,” your claim must be submitted by the insurance company in accordance
with their “Right of Subrogation,” even if you are looking for reimbursement for a
deductible.
3. Accident/Incident Information:
Date:
Time:
Location of Accident/Incident:
State Highway
Nearest Intersection
Direction of Travel
Distance from
Landmark
Reference/Mile Marker
Town, City or Village
County
Detailed description of what happened:
DC30-2 (4/15)
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Parent category: Legal