Claim/Incident Reporting Form

The Corporation of the

City of Kawartha Lakes

Risk Management

P.O. Box 9000, 26 Francis St.

Lindsay, ON K9V 5R8

Tel: (705) 324-9411 ext 1380

CLAIM REPORT Fax: (705) 324-7058

E-Mail: riskmanagement@kawarthalakes.ca

The City of Kawartha Lakes claims process is located on our website at www.kawarthalakes.ca

NOTE: THERE IS A 10 DAY NOTICE PERIOD FOR PROVIDING THE CITY WITH NOTICE OF CERTAIN TYPES OF CLAIMS AND A TWO YEAR LIMITATION PERIOD FOR BRINGING AN ACTION IN RESPECT TO MOST CLAIMS.

PLEASE PROVIDE/ATTACH PHOTOS, INVOICES, AND ANY OTHER RELEVANT DOCUMENTATION IN THE ATTACHMENTS SECTION IN SUPPORT OF YOUR CLAIM ALONG WITH THIS CLAIM FORM

Incident/Claim Information

Incident Type

Incident Date/Time

AM/PM

Incident Address of City Facility

Incident City

Incident Description

Vehicle Involved?

Property Damage to Others?

Estimated Damages/Losses ($)

Please insert dollar amount only.

Reporter Details

"Reporter" is the person filling out this form

Involvement Type

First Name

Last Name

Birthdate

MM/DD/YYYY

Phone

Mobile Phone

Mailing Street

Mailing City

Mailing State/Province

Mailing Country

Mailing Zip/Postal Code

Description of Damage or Personal Injuries

Care from Emergency Medical Services?

Badge No. / Police Report No.

Seek Medical Attention?

Health care provider's name

Do you wish to add Involved Persons?

"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

First Name

Last Name

Birthdate

Phone

Mobile Phone

Mailing Street

Mailing City

Mailing State/Province

Mailing Country

Mailing Zip/Postal Code

Sustained Injury?

Seek Medical Attention?

Care from Emergency Medical Services?

Description of Personal Injuries

Health care provider's name

Call Phone Number from Ambulance Call Report

Have you received any other medical aid?

Part of Body

Select multiple by holding "ctrl".

Nature of Injury

Select multiple by holding "ctrl".

To add another involved person, please select "Add another response" on the bottom-right portion of this section. This will open another section where information can inserted. If not required, please ignore.

3rd Party Involved Vehicle

Note: If you do not know the make of the vehicle, please put "N/A"

3rd Party Vehicle Make

If make not known, please insert "N/A"

3rd Party Vehicle Model

3rd Party Vehicle License Plate Number

3rd Party Vehicle Year

Vehicle Type

Description of Damages

To add another vehicle, please select "Add another response" on the bottom-right portion of this section.

Attachments

Do you wish to add Files/Attachments?

Note: There is a 25 MB per file size limit, a 35 MB total file size limit, and a 10 file limit per submission.

Please upload any supporting documents, images, invoices, or estimate of damages.

File Upload

To add more than one attachment, select "Add Another Response". To remove the additional file upload option, select "Remove".

Additional Information or Comments

Please enter any additional information or comments here.

Declaration

I confirm that all information submitted is accurate, correct and complete to the best of my knowledge. I further understand that false or fraudulent claims cost all taxpayers and for this reason any such claims will be prosecuted to the full extent of the law.

I understand that the use of profanity, abuse, threat or cyber bullying may cause the City of Kawartha Lakes staff and/or independent adjusters assigned to the claim to provide no further contact, support or consideration of this claim. Upon submission of this claim form, I understand and agree that the entire claim process will be investigated and managed completely by an independent adjusting firm. All my emails, calls or other contact regarding the claim are to be delivered solely to the independent adjuster assigned to the claim. By signing this form I approve and understand that if a contractor had control of the area where the incident took place, this form will be directed by the independent adjuster to the contractor for its investigation and liability consideration.

I agree

The personal information collected to investigate your claim is collected under the authority of the Municipal

Act 2001, S.O. 2001, c. 29 and will be disclosed to staff and service providers who require the information

to investigate your claim against the City of Kawartha Lakes. Questions about the collection of this

personal information should be directed to the City Clerk or Deputy Clerk at (705) 324-9411 extension 1295

or 1322.