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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

Incident Details

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

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

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

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Did you Report the Incident to the City?
 

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

Witness Information

Agreement

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

I Agree to Terms
 

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