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Compensation Claim Form

Type of claim

Select type of claim being made *

Type of compensation sought

Select type of compensation being sought *

Contact details

Title

Correspondence

Do you agree for all correspondence to be sent to you by email? *

Incident details

Time of incident
:
Did you contact Council staff at the time of the incident?

Compensation sought

Please also note that the request of this information must not be seen as an automatic acceptance of liability. All claims are assessed based on their own merit and any payments made will come from Council funds.
For property/vehicle damage claims, attach any supporting documentation to substantiate your loss.
Maximum upload size: 10MB

Insurance details

Have you claimed against your insurer? *

Witness details

Did anyone witness the incident?
Please attach a witness statement. Note: Council will not contact the nominated witness should a statement not be attached. A decision will be made in the absence of such evidence
Maximum upload size: 10MB

Evidence

Do you wish to attach evidence to this form?
Maximum upload size: 10MB

Authority for an agent to act

Do you wish for a third party to act on your behalf in this claim?

Electronic confirmation

Council will investigate the circumstances surrounding your claim to establish whether or not Council has any legal liability. Completion and acceptance of this form does not represent an admission of liability or a waiver of its rights on the part of Council. Your claim will be subject to investigation and the findings assessed on their own merits. Council will endeavour to respond to claims as quickly as possible. However the processing of claims is dependent on the supply of relevant information and assessment of your claim may take some time to complete.
I confirm the information is correct *