Property Damage Or Loss Claim Form - New York City Page 4
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4Office of the New York City Comptroller
1 Centre Street
New York City Comptroller
New York, NY 10007
Scott M. Stringer
Insurance Information
City vehicle information
Do you have insurance?
Yes
No
Plate #:
Did you report your accident to your insurance
Yes
No
company?
Yes
No
Were you paid by your insurance company?
City Driver Last
Name:
Is payment pending?
Yes
No
City Driver First
Deductible Amount:
Name:
Insurance Company
*Total Amount
Name:
Claimed:
Address:
Format: Do not
Address 2:
include "$" or ",".
City:
State:
Zip Code:
Policy #:
Phone #:
Agent Name:
_______________________________________________________ __________________________________________________________
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_________________________________________
* Denotes required field(s).
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