Form Builder

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, 100 Wellington Square, Brantford, ON, N3T 2M3, (519) 759-4150

Claimant's Personal Information

Incident Details

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

Upload a Photo or a Diagram

Maximum size: 5 mb, Allowed File Extensions: JPG, JPEG, PNG and PDF

Browse…

Allowed extensions JPG, JPEG, PNG, PDF

Witness Information

Agreement

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

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
100 Wellington Square
Brantford, ON N3T 2M2
Telephone: 519-759-4150
Email: claims@brantford.ca