Notice Of Intention To Make Claim Form
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1
2Notice of Intention to Make Claim
This form must be subscribed and sworn to.
Fax or e-mail notification is not acceptable.
To: MOTOR VEHICLE ACCIDENT INDEMNIFICATION CORPORATION
th
100 WILLIAM ST, 14
Floor
NEW YORK, N.Y. 10038
phone: 646-205-7800
State of New York
-
County of ___________________
-ss.
Pursuant to Article 52 and/or pertinent sections of Article 18 of the Insurance Law of
the State of New York, this affidavit is presented to the Motor Vehicle Accident
Indemnification Corporation for the purpose of giving my Notice of Intention to Make
Claim against said Motor Vehicle Accident Corp. for injuries sustained by me. I have
been duly sworn and state:
My name is ____________________________; my date of birth is __________________
I reside at _____________________________;____________________________________________
Street Address /Apt
City
-
State
-
Zipcode
My Social Security # is: _________________
My email is: ___________________________
My telephone number is: ______________
I am employed by: _____________________________
[ ] Unemployed
_____________________________
_____________________________
I was involved in an automobile accident on: ________________________________________
Month
Day
Year
time (am/pm)
Place of Accident: ____________________________________________________________________
Street or highway
City
State
I was
driver [ ]
a passenger [ ]
of vehicle #1 [ ]
a pedestrian [ ]
vehicle #2 [ ]
a bicyclist
[ ]
Vehicle #1 ______________________________ Vehicle #2__________________________________
Year/Make/Model/Color
Year/Make/Model/Color
License Plate #:_______________State______ License Plate #:____________State____
Owner:__________________________________ Owner: _____________________________
Address:________________________________ Address:____________________________
________________________________
___________________________
Driver:__________________________________ Driver:______________________________
Address:________________________________ Address:____________________________
________________________________
___________________________
Insured by:______________________________
Insured by:_________________________
Policy #:_________________________________
Policy #:____________________________
Effective Date:___________Expiration date:_____ Effective Date:__________Expiration date:_____
The accident was reported to the Police on ______________, in _________________________________
Date
Precinct - City – State
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