Beruflich Dokumente
Kultur Dokumente
_______ ________________
_______________________________________________________________________________________________________________________________________
Address
Borough
Zip Code
_______________________________________________________________________________________________________________________________________
Date of Birth
Social Security #
Telephone #
_______________________________________________________________________________________________________________________________________
Cell #
Fax #
E-Mail Address
_______________________________________________________________________________________________________________________________________
3 DRIVERS INFORMATION
Last Name
First Name
S.S.# _______-______-_______
4 INSURANCE INFORMATION
Name of Carrier: ________________________________________________________________________________________________________________________
Complete Street Address: _________________________________________________________________________________________________________________
Policy Number: ________________________________ Name of Agent: _______________________________ Tel#: (_______)______________________________
Do you have
[ ] Yes
Collision Insurance? [ ] No
[ ]Yes
[ ]No
[ ]Yes
[ ]No
Amount of
Deductible? ________________
5 ACCIDENT INFORMATION
Exact Date of Occurrence:
pm:________
6 TOW CLAIMS
Exact Date of Tow:
Month: _________
Day: ________
Year: ________
Time: _________
am: _______
pm: ______
Location Vehicle was picked up at: ______________________________________ Receipt#: _______________________ Voucher#: ___________________________
Description:
Cost:
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
__________________________________________________________________________________________
_______________________________________________________________________________________________________________________________________
Last Name
First Name
Title
_______________________________________________________________________________________________________________________________________
Complete Street Address
(Number, Street, City (Boro), State, Zip +4
City Agency Employed By: ________________________________________________________________________________________________________________
Type of Vehicle: _______________________________________ License Plate#:___________________________
Beeper/Cell: _________________________
Signature X: ____________________________________________________________________________________________________________________________
PLEASE PROVIDE THE RELEVANT INFORMATION FOR THE FOLLOWING APPLICABLE ITEMS AND RETURN THE
FORM PROMPTLY ALONG WITH THE MAIN CLAIM FORM.
NYC
[ ] Going Straight Ahead
[ ] Making a Right Turn
[
] Making a Left Turn
[
] Making a U-Turn
[ ] Starting From Parked Position
[
] Starting in Traffic
Yours
[
]
[
]
[
]
[
]
[
]
NYC
[ ] Slowing or Stopping
[ ] Stopped in Traffic
[
] Entering a Parked Position
[
] Parked
[
] Avoiding Object in Roadway
WEATHER:
[ ] Clear
[ ] Snow
[ ] Rain
[ ] Other
[ ] Fog/Smog/Smoke
[ ] Sleet/Hail/Freezing Rain
Yours
[
]
[
]
[
]
[
]
[
]
NYC
[
] Overtaking
[
] Merging
[
] Backing
[
] Other
[
] Changing Lanes
TRAFFIC CONTROL:
[ ] None
[ ] Yield Sign
[ ] Red - Green
[ ] Other
[ ] Red Yellow Green
[ ] Stop Sign
[ ] Flashing
[ ] Person Directing Traffic
[ ] Not working
_______________________________________________________________________________________________________________________________________
Accident Diagram: Number all the Vehicles
Yes ________
No _________
Yes ________
No ________
Yes ________
Yes __________
_________________________________________________________________________________________________________________
G What are the measurements of the defect?
Length: ____________
Width: ______________
Depth: ____________
11 NOTARY CERTIFICATION
Claimants signature: ______________________________________________________________
Date: __________________________
_______________________________________________________________________________________________________________________________________
State of New York
] ss:
County of
___________________________________________________________________ being duly sworn deposes and says that I have read the foregoing NOTICE OF
(PRINT NAME)
CLAIM and know the contents thereof; that the same is true to the best of my own knowledge except as to the matters therein stated to be alleged upon information and
belief, and as to those matters. I believe them to be true.
Signature of Claimant: X: _________________________________________________________
Date: ____________________________________________
IMPORTANT: IF THE CLAIM IS NOT SETTLED, YOU MUST START LEGAL ACTION WITHIN ONE YAR AND NINETY DAYS FROM THE DATE OF THE
INCIDENT.
NOTARY PUBLIC STAMP