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* Denotes that the field is mandatory.
Insurance Claim

Council will investigate the circumstances surrounding the incident to establish whether or not Council has
any legal liability. Click here for more information.

Contact Details
First Name *
Surname *
Postal Address *
E-Mail Address *
Mobile Phone
Phone Number *
Type of Loss Suffered
For property/vehicle damage claims, please attach any supporting documentation to substantiate your loss
Type of compensation being
sought *
Do you agree for all
correspondence to be sent
to you via email? *
Attach Supporting Documentation
here
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Incident Details
Date of Incident *
Time of Incident *
Exact Location of Incident *
Incident Details *
Did you contact Council staff at the
time of the incident *
If yes - provide details *
Insurance Detail
Have you claimed against your
insurance?
Claim/Policy Number
Insurance Provider
Contact Name
Conctact Telephone Number
Witness
Did anyone witness the incident
Witness Contact name
Witness Contact number
Witness Email
Witness Address
Evidence
In order to progress your claim for compensation you will be required to establish that Council caused the alleged loss and/or damage through some form of negligence.

In any public liability claim, the burden of providing proof of negligence rests with you as the person seeking compensation. Council cannot assist you in this
Is the evidence referenced
uploaded to this form? *
Please explain any evidence you
are supplying
Attach Supporting Evidence here
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Authority for an Agent to Act
Do you wish for a third party to act
on your behalf in this claim? *
Agent Name
Agent Postal Address
Agent email
Agent Contact telephone number
Declaration
I declare that the information supplied to Council in this claim is true and correct and confirm that the statements are honestly made.
Completion and acceptance of this claim (including completion of the Authority for an Agent to Act), when completed does not
represent an admission of liability on the part of Council and/or their insurers.

Your claim for compensation will be subject to investigation and will be assessed on its own merits.
I declare that the information
supplied to Council in this claim
is true and correct.
Further Supporting Documentation
Attach any other documentation that may assist Council evaluation your claim
Attachment
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Attachment
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Privacy Notice: Livingstone Shire Council is collecting the information you supply via this online service for the purpose of processing your transaction. Your personal details will not be disclosed to any other person or agency external to Council without your consent unless required by relevant legislation or authorised by law.

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