Incident Form
Are you submitting a claim on behalf of a individual or corporation?
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Individual
Corporation
I hereby give consent to the City of Sault Ste. Marie to collect, use, or disclose my information that is necessary and reasonable for the purposes of processing my claim
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No
Yes
NOTE: If you select 'No', the City of Sault Ste. Marie is unable to accept your online form as notice to the City about your claim.
Claimant Information
Corporation Name
First Name
Last Name
Mailing Address
City
Province
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Postal Code
Primary Phone
Secondary Phone
Email
Is this Contact Information different than Claimant Information?
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No
Yes
Contact Information
First Name
Last Name
Mailing Address
City
Province
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Alberta
British Columbia
Manitoba
New Brunswick
Newfoundland and Labrador
Nova Scotia
Northwest Territories
Nunavut
Ontario
Prince Edward Island
Quebec
Saskatchewan
Yukon Territory
Postal Code
Primary Phone
Secondary Phone
Email
Relationship to Claimant
Incident Information
Date of Incident
Time of Incident
HH:MM pm or HH:MM am
Address or approximate location of incident
Description of Incident
Please provide specific information regarding the events surrounding your claim.
Costs Incurred
What costs, if any, have you incurred as a result of this incident? Please provide supporting documentation.
Weather
Clear
Rain
Snow
Fog
Freezing Rain
Hail
Road Condition
Paved
Unpaved
Off-road
Light
Daylight
Dawn
Dusk
Dark
Additional Details
This claim involves a vehicle.
There was property damage.
Personal injuries were sustained.
There was construction in the area.
Your insurance provider has been notified.
A police report was filled.
Police Report
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 report the accident to the nearest police officer forthwith.
Collision Number
From Motor Vehicle Collision Report
Police Agency
Ex: SSM Police Service, OPP, etc
Officer's Name
Badge Number
Vehicle Incident Information
Vehicle License Plate Number
Vehicle Year
Vehicle Model
Vehicle Colour
Vehicle VIN Number
Property Damage Information
Description of Property Damage
Please provide specific information regarding the damage sustained to your personal property.
Insurance Provider Information
Insurance Company
Claim Number
Adjuster Name (assigned to your claim)
Personal Injury Information
Please provide specific information regarding the medical aid you received and/or are receiving as a result of the incident
Did you receive care from Emergency Medical Services personnel (i.e., was an ambulance called)?
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No
Yes
Call Number from Ambulance Call Report
Have you received any other medical aid?
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No
Yes
Health care provider's name
Description of personal injuries
Please provide specific information regarding the injuries you sustained.
Part of Body
Abdomen
Back lower
Back upper
Bladder
Brain
Buttocks
Chest and/or ribs
Chin
Circulatory system
Collar bone
Digestive system
Face and facial bones
Finger(s)
Groin
Head
Heart
Hip
Kidney(s)
Larnyx
Left ankle
Left arm
Left ear
Left elbow
Left eye
Left foot
Left hand
Left knee
Left leg
Left lung
Left shoulder
Left wrist
Liver
Mouth
Multiple body parts or systems
Neck
Nervous system
No physical injury
Nose
Not otherwise classified
Pancreas
Pelvis
Reproductive system
Respiratory system
Right ankle
Right arm
Right ear
Right elbow
Right eye
Right foot
Right hand
Right knee
Right leg
Right lung
Right shoulder
Right wrist
Sacrum or coccyx
Skull
Spinal cord/column/vertebra/disc
Spleen
Stomach
Thumb
Toe
Tooth
Trachea
Nature of Injury
Allergic reaction
Amputation
Arthritis
Asbestos
Asphyxia
Bite or sting
Brain damage
Burn (chemical or heat)
Carpal tunnel syndrome
Choking
Communicable disease
Concussion
Contusion, bruise
Crushing
Cumulative injuries
Death
Dermatitis, skin disease or disorder
Dislocation
Ear disease or disorder
Electric Shock
Eye disease or disorder
Foreign Body
Fracture
Frostbite, hypothermia
Heart attach (myocardial infarction)
Hernia, herniation, rupture
Infection
Inflammation/irritation of joint/nerve
Laceration, open wound
Medication errors
Multiple injuries
Nausea
No physical injury
Not otherwise classified
Occupational health disorder, NOC
Poisoning - occup. disease or cum. inj.
Poisoning - trauma
Property damage
Prosthetic devices
Psychological problems/mental anguish
Puncture
Quadriplegic
Respiratory disorders
Scarring/Disfigurement
Scratch, abrasion
Seizure
Sprain
Strain
Stroke
Syncope (dizziness)
Torn cartilage/ligament/tendon
There was Construction in the Area
Construction Company
Attachments
Please include copies of all documentation you currently have related to this incident so that your claim can be considered. Additional documentation subsequent to submitting this form should be forwarded to the City's Legal Department for further consideration.
Attachment 1
Form Encrypted - While your form data will be encrypted, file uploads are stored unencrypted and will be hosted publicly on a 3rd party CDN. Note: There is a 35mb limit per file upload.
Attachment 2
Form Encrypted - While your form data will be encrypted, file uploads are stored unencrypted and will be hosted publicly on a 3rd party CDN. Note: There is a 35mb limit per file upload.
Attachment 3
Form Encrypted - While your form data will be encrypted, file uploads are stored unencrypted and will be hosted publicly on a 3rd party CDN. Note: There is a 35mb limit per file upload.
Attachment 4
Form Encrypted - While your form data will be encrypted, file uploads are stored unencrypted and will be hosted publicly on a 3rd party CDN. Note: There is a 35mb limit per file upload.
Attachment 5
Form Encrypted - While your form data will be encrypted, file uploads are stored unencrypted and will be hosted publicly on a 3rd party CDN. Note: There is a 35mb limit per file upload.
Attachment 6
Form Encrypted - While your form data will be encrypted, file uploads are stored unencrypted and will be hosted publicly on a 3rd party CDN. Note: There is a 35mb limit per file upload.
Any person who, with intent to defraud or knowing that he/she is facilitating a fraud, or submits an application or files a claim containing a false or deceptive statement, is guilty of fraud.
If you have any knowledge that the alleged damages might have occurred as a result of work being performed by a contractor on behalf of The Corporation of Sault Ste. Marie (the "City") or a public utility, please report this information to the City Clerk's Department immediately (705-759-5388).
The personal information contained on this form shall be used solely for the purpose of processing the damage and/or personal injury claim and will be supplied to the City’s insurance adjuster and/or to those from whom the City is claiming contribution or indemnity. Questions about this collection of information can be made to the City's Legal Department (705-759-5400).
Date
Contact Information