Public - Injury/Property Damage Report

Any information which you provide on this on-line form will be kept confidential. 

Personal information on this form is collected under the authority of the Municipal Act 2001, S.O. 2001, C.25 and will be used to process your claim with the City of London. Questions about the collection of this personal information should be directed to the Manager, Risk Management, 300 Dufferin Avenue, London, ON N6A 4L9 519-661-CITY (2489) ext. 5435.
Type of Claim
Property Injury Vehicle
Personal Information










Incident Information

Click to view calendar

HH

MM



















Property Information

Vehicle






Injury





Name and address of parent/guardian (if injured person is under age 18)






PLEASE PROVIDE/ATTACH PHOTOS, INVOICES, AND ANY OTHER RELEVANT DOCUMENTATION IN SUPPORT OF YOUR CLAIM.
Attachments








This request for information does not constitute an acceptance of your claim but permits the Corporation of the City of London or its Insurance Representatives to properly record and investigate your claim.

Our employees are instructed to provide this form to you and are not authorized to accept responsibility for claims made. It may be in your best interests to report this matter to your own insurance company.

Please note that claims which are not delivered to the City Clerk within ten (10) days from the time injury or damages were sustained may be statute barred. Also note that legal action which is not brought or commenced within two years from the time injury or damages were sustained may be statute barred.

THE INFORMATION PROVIDED HEREIN IS TRUE, I UNDERSTAND THAT FRAUDULENT CLAIMS COST ALL TAXPAYERS, AND FOR THIS REASON, ALL FRAUDULENT CLAIMS WILL BE PROSECUTED TO THE FULL EXTENT OF THE LAW.

You will be contacted in writing in the near future. Thank you for your co-operation.

Contact Information