By clicking “I Agree,” I certify that all information to be provided is true and correct to the best of my knowledge and belief. I understand that the willful making of any false statement of material fact herein will subject me to criminal penalties and civil liabilities.

NOTE: As of June 27th, 2022 the PDF electronic claim forms have been revised. Older versions of the form will no longer be accepted. Check the form version in the upper right hand corner of the first page, and be sure it is one of the following (or newer):

• NYC-COMPT-BLA-PI1-E (Personal Injury)
• NYC-COMPT-BLA-PD1-E (Property Damage or Loss)
• NYC-COMPT-BLA-PD2-E (Water Damage or Loss)
• NYC-COMPT-BLA-PD3-E (Vehicular Property Damage)
• NYC-COMPT-BLA-LE-C4 (City Employment)

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