test-form Compensation Claim Form Type of claim Select type of claim being made * Road Footpath Tree Drainage Type of compensation sought Select type of compensation being sought * Property damage Personal injury Motor vehicle OtherOther Contact details Title Mr Mrs Ms OtherOther Name * Address Suburb/Town Phone Email * Correspondence Do you agree for all correspondence to be sent to you by email? * Yes No Provide preferred method of contact Incident details Date of incident Time of incident 121234567891011 : 0030 AMPM Location of incident Closest cross street/s to the incident What occured? Did you contact Council staff at the time of the incident? Yes No Provide name/details of Council officer 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. Details For property/vehicle damage claims, attach any supporting documentation to substantiate your loss. File Upload Drop a file here or click to upload Choose File Maximum upload size: 10MB Insurance details Have you claimed against your insurer? * Yes No Claim/Policy number Insurance provider Contact name Phone Witness details Did anyone witness the incident? Yes No 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 File Upload Drop a file here or click to upload Choose File Maximum upload size: 10MB Name Phone Email Address Town/Suburb Evidence Do you wish to attach evidence to this form? Yes No Please explain any evidence you are supplying File Upload Drop a file here or click to upload Choose File 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? Yes No Name Phone Email Address Suburb 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 * Confirm reCAPTCHA If you are human, leave this field blank. Submit
