Personal Information on this form is collected under the authority of the Municipal Act 2001, C.25 and will be used to process your claim with the City of Vaughan. Questions about this collection may be directed to the Claims Analyst, located in the Office of the City Clerk.

City of Vaughan		Ph: 905-832-8585
Office of the City Clerk Insurance & Risk Management Section		Fx: 905-832-8535
2141 Major Mackenzie Drive		Email: claimservices@vaughan.ca
Vaughan, Ontario
L6A 1T1

Notices should be submitted to the City within ten (10) days of the incident. A two (2) year limitation period to submit a claim action will apply as per Section 4 of the Limitations Act, 2002 S.O. 2002, Chapter 24, Schedule B.

All claims submitted are to be made in writing as per the Municipal Act and submitted to the Office of the City Clerk. Completing this form online is equivalent to submitting it in writing.

Claimant Information

Is the Claimant an Individual or a Company?

Company Name

First Name

Last Name

Street Number

Street Name

Apartment Unit Number

City

Province

Postal Code

Which Phone Number would you like to provide for contact (please select any number, minimum of one)

CellHomeWork

Cell Phone

Home Phone

Work Phone

Date of Birth

Click field to select by calendar or type manually

Are you the Claimant's Legal Counsel?

Is Contact Information different from the claimant or Legal Counsel information?

Counsel Information

Counsel Name	Company/Firm Name
Address	Counsel File Number
Phone Number	Fax Number
Email	Retained Date

Contact Information

Contact Type

Adjuster Name

Company

Mailing Address

City

Province

Postal Code

Phone

File Number

Representative Name

Company

Mailing Address

City

Province

Postal Code

Phone

Policy Number

Claim Number

Contact Name

Relationship to Claimant

Mailing Address

City

Province

Postal Code

Phone

Incident Information

Date of Incident

Click field to select by calendar or type manually

Time of Incident

Hour

Minute

AM/PM

Address or approximate location of incident

Description of Incident

Please provide specific information regarding the events surrounding your claim.

Costs Incurred

Retain all written proof (i.e. invoices) of the “Costs Incurred”, as these will be required.

Did the incident occur inside a City Building?

Name of Facility

Address of Facility

Was Weather a Factor?	Weather
Light	Surface Condition

Additional Details (Check all that apply)

This claim involves a vehicleThere was property damagePersonal Injuries were sustainedThere was construction in the areaYour insurance provider has been notifiedA police report was filed

Were There Any Witnesses?

Witness Information

Witness 1

First Name	Initial	Last Name
Number	Street	Address Unit Number
City	Province	Postal Code
Home Phone	Work Phone	Email

Witness 2

First Name	Initial	Last Name
Number	Street	Address Unit Number
City	Province	Postal Code
Home Phone	Work Phone	Email

Vehicle Incident Information

Vehicle License Plate Number

Vehicle Year

Vehicle Model

Vehicle Colour

Vehicle ID Number (VIN)

Property Damage Information

Description of Property Damage

Please provide specific information regarding the damage sustained to your personal property

There Was Construction in the Area

Construction Company

Insurance Provider Information

Insurance Company

Claim Number

Adjuster Name (assigned to your claim)

Police Information

Note: Pursuant to s. 199 (1) of the Highway Traffic Act, R.S.O 1990, c. H. 8, individuals who are involved, either directly or indirectly, in a vehicle-related accident that results in personal injuries or property damage in excess of $2,000.00 must report the accident to the nearest police officer forthwith.

Collision Number

Police Agency

Officer's Name

Badge Number

Attachments

Attachments in the form of: invoices, estimates, photographs, medical reports etc., should be included in your submission as supporting documentation to provide explanatory information related to your claim.

Photographs of the location where the loss occurred should be in colour. If the photograph is of a

location where an injury occurred, please mark the exact location on the photograph with an X.

Ensure to make copies of all documentation submitted, as it will not be returned and will become the property of the City of Vaughan.

NOTE: The maximum allowable size of a single attachment is 25 MB, and the maximum allowable TOTAL size of ALL attachments is 35 MB.

Attachment 01

Attachment 02

Attachment 03

Attachment 04

Additional Attachments?

Attachment 05

Attachment 06

Attachment 07

Attachment 08

Attachment 09

Attachment 10

Attachment 11

Attachment 12

DECLARATION

The information provided herein is true. I understand that submitting false statements and/or

documentation is a form of fraud and is illegal. I acknowledge that fraudulent claims cost taxpayers, and that claims that are determined to be made fraudulently will be prosecuted to the full extent of the law.

I hereby give consent to the City of Vaughan to collect, use or disclose my information that is necessary and reasonable for the purposes of processing my claim.

I accept that the City will disclose my personal information to the City’s insurance adjuster and/or to those involved in the resulting claim resolution, including but not limited to lawyers, or third parties that are found responsible for losses claimed.

I have read, acknowledge and understand the consequences and agree with the statement above

I AgreeNOTE: If you do not agree, the City of Vaughan is unable to accept your on-line form as notice to the City about your claim.

Claimant Information

Counsel Information

Contact Information

Incident Information

Witness Information

Vehicle Incident Information

Property Damage Information

Personal Injury Information

There Was Construction in the Area

Insurance Provider Information

Police Information

Attachments

DECLARATION