Submit a Claim/Incident

Note: All fields with a red asterisk (*) and include "(Required)" must be completed in order to submit the form.

Municipality

Email List

Incident/Claim Details

Type of Incident/Claim (Required)

Incident Date (Required)

FORMAT: MM/DD/YYYY (Month/Day/Year)

NOTE: Incident Date must be entered in the following format: MM/DD/YYYY in the text box above. For example, August 24, 2021 should be input as 08/24/2021. A calendar will also appear if the text box is clicked on.

Incident Time

FORMAT: ##:## (AM/PM) - EXAMPLE: 05:38 PM

Incident Address/Location

Incident Town/City

Incident Description (Required)

Reporter Details

"Reporter" is the person filling out this form

Involvement Type (Required)

First Name (Required)

Last Name (Required)

Phone (Required)

Mobile Phone

Street Address (Required)

City (Required)

Province (Required)

Postal Code (Required)

Did this person sustain an Injury? (Required)

Description of Personal Injuries

Do you wish to add "Involved Persons" to this report? (Required)

"Involved Person" is an individual who is/may be involved with the claim/incident (directly or indirectly) being reported. (Examples include the claimant, witness to the Incident, lawyer, property manager, employees, etc.)

Involved Person Details

Involvement Type (Required)

First Name (Required)

Last Name (Required)

Phone (Required)

Mobile Phone

Street Address

City

Province

Postal Code

Country

Did this person sustain an Injury? (Required)

Description of Personal Injuries

To add more individuals to this report, such as another witness or person affected, please select "Add Another Involved Person" below. This will open another section where information can be inserted. If not required, please ignore. If you selected to add another involved person and no longer require it, please select "Remove" on the new involved person details section.

Attachments

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

Please upload any supporting documents, images, invoices, or estimate of damages. Should you have more than 10 attachments to submit or encounter difficulties uploading a file, please note that you can email these files directly to the examiner assigned once your claim is setup.

To add more files to this report, please select "Add Another File Upload" below. This will open another section where information can be inserted. If not required, please ignore. If you selected to add another file upload and no longer require it, please select "Remove" on the new file upload section.

Do you have any files for upload? (Required)

File Upload (Required)

Incident/Claim Submission

Limitations and timelines

There may be a limitation period and other procedural timelines that apply to your claim. You should consult your own legal counsel or insurer as needed.

Claim process

When your claim is received by the Municipal Clerk, it will be date stamped to note the time of receipt. Your claim will then be forwarded to the Durham Municipal Insurance Pool for investigation

and response. This claim process may take time, so you should consult your own legal counsel or insurer if you need an immediate response.

Liability and legal rights

Following this procedure does not mean that the Municipality is accepting liability for your claim. It

does not waive any legal rights that you and/or the Municipality may be able to rely on.

Personal information contained on this form is collected pursuant to the Municipal Act 2001, and in accordance with the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA). Personal information on this Application will be used to assist in the service of your claim submission and may be subject to disclosure under the MFIPPA if circumstances warrant. Questions regarding the collection, use and disclosure of personal information should be directed to the Corporate Privacy Officer at foi@durham.ca, 905-668 7711 ext. 2204 or 1-800-372-1102.

In order to proceed with form submission, "I Consent" must be selected below.

I Consent

Contact Information