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Notice of Claim

This notice of Claim is for information only and does not infer acceptance of liability by the City of Brantford.

Notice of Collection of Personal Information: The personal information collected on this form is collected under the authority of sections 279(1) and 10(1) of the Municipal Act, 2001 as amended, and will be used to contact claimants to process a claim filed against the municipality.

Questions about this collection should be directed to the Claims & Insurance Analyst, 58 Dalhousie Street, Brantford, Ontario N3T 2J2, (519) 759-4150

Claimant's Personal Information

First Name (required)

Last Name (required)

Mailing Address (required)

City (required)

Province (required)

Postal Code (required)

Home Phone (required)

Cell or Alternative Number

Email Address (required)

Incident Details

Incident Date (MM/dd/yyyy)

Time of Incident (12 Hour AM/PM)

Incident Location or Facility

Persons or Vehicle/Equipment Involved

Damage or Injury (required)

To substantiate your claim, provide original purchase receipts, repair estimates, photos, or other evidence.

Estimated Amount of Claim

Did the incident occur as a result of work being performed by a contractor?

Yes

If yes, please provide the name of the contractor on the contact person, if known

Did any emergency personnel attend such as paramedics, police or fire?

Yes

If yes, please provide names(s), badge #, occurrence #, contact information and file number(s)

Description of Incident

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Did you Report the Incident to the City?

Yes

Details of name(s) of City Staff and/or Department Involved

Have you claimed, or will you be claiming any compensation from an insurance provider?

Yes

If yes, please provide the name and contact information of your insurance provider(s) and the number(s)

Witness Information

First Name

Last Name

Mailing Address

City

Province

Postal code

Home Phone

Cell or Alternative Phone

Email Address

Agreement

The information provided herein is factual and a true account of my claim.

I Agree to Terms

Yes

Name

Personal information on this form is collected under the authority of Section 10(1) of the Municipal Act, 2001, S.O. 2001, c.25, as amended and will be used to contact you concerning your service request/inquiry to the City of Brantford. Questions about this collection should be directed to:

City of Brantford Customer Contact Centre
Brantford City Hall
58 Dalhousie Street, Brantford, Ontario N3T 2J2
Telephone: 519-759-4150
Email: claims@brantford.ca