* 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.

Contact Details

First Name *
*
Surname *
*
Postal Address *
*
E-Mail Address
Do you agree for all
correspondence to be sent
to you via email? *
*
Mobile Phone
Phone Number *
*

Type of Loss Suffered

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 with this process
Type of compensation being
sought *
*
If Other - provide details
Desired outcome you are seeking
from Council

Motor Vehicle Details (if Applicable)

Year of Manufacture
Make of Vehicle
Model
Registration Number

Incident Details

Date of Incident *
*Date is invalid.
Time of Incident *
*
Exact Location of Incident *
*
Incident Details *
*
Did you contact Council staff at the
time of the incident *
*
If yes - provide details *
*

Evidence

Please explain any evidence you
are supplying
Attach Supporting Evidence *
  *

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

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

Attachment Description
Attachment

Attachment Description