City of Windsor Damage Claim Form

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1 Uppercase letter
1 Lowercase letter
1 Number
1 Special character

CLAIMANT DETAILS

Prefix

First Name

Last Name

Contact Preference

Street Address

City

Province

Postal Code

Country

Home Phone

Work Phone

Cell Phone

Ext. Number

Email Address

INCIDENT DETAILS

Date of Incident

AM/PM

Location

Incident Details

Please provide specific information regarding this incident.

Environmental Conditions

Please specify whether you believe weather or other environmental conditions caused or contributed to the incident, and provide details of same.

Did you place a 311 call?

YesNo

311 Reference Number (if known)

Are you represented by legal counsel?

YesNo

Name of Lawyer

Name of Law Firm

ATTACHMENTS AND FILES

Please provide images in jpeg format.

Note: There is a 25 MB per file size limit and a 35 MB total file size limit per submission.

Attachment 01

Attachment 02

Attachment 03

Attachment 04

Are there more attachments or files to be included with this submission?

YesNo

Attachment 05

Attachment 06

Attachment 07

Attachment 08

Attachment 09

Attachment 10

Attachment 11

Attachment 12

ATTACHMENTS AND FILES

Please use the following link to include supporting pictures and/or files. Make sure to enter your name in the space provided.

https://simpleforms.citywindsor.ca/DamageClaim/Applications/Create

SUBMITTER DETAILS

Submitter Email Address

Any person(s) who, with intent to defraud or knowing that he/she is facilitating a fraud against an insurer, submits an application or files a claim containing a false or deceptive statement, is guilty of insurance fraud. I agree that what I have submitted is true to the best of my knowledge and belief.

I Agree

If you believe the conditions giving rise to your claim pose an immediate threat to health and safety, please report to 311.

The personal information on this form is collected under the authority of the Municipal Act, 2001, s.10. The information is used solely for the purpose of processing the damage claim and will be supplied to the City of Windsor’s insurance adjuster and to those from whom the City is claiming contribution or indemnity. Questions about this collection of information can be made to the Supervisor, Information and Records, 519-255-6222 ext. 6214.

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Contact Information