Submit a Claim/Incident

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

PERSONAL INFORMATION ON THIS FORM IS COLLECTED UNDER THE AUTHORITY OF THE MUNICIPAL ACT 2001, C.25 AND WILL BE USED TO PROCESS YOUR CLAIM. QUESTIONS ABOUT THIS COLLECTION MAY BE DIRECTED TO THE EXAMINER ASSIGNED TO YOUR CLAIM.

Collection Consent: Does the Town of Halton Hills have your consent to collect, use or disclose your information that is necessary and reasonable for the purposes of processing your claim?

Purpose: If you have suffered a loss for which you believe the Town may be responsible, you can file a claim against the Town using this form. In situations involving disrepair of a road or sidewalk, you will be required to provide notice to the Town within 10 days of the incident. A two (2) year limitation period to submit a claim action will apply as per Section 4 of the Limitations Act, 2002 S.O. 2002, Chapter 24, Schedule B. If you have questions regarding this form, please click here.

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.

Please fully and clearly describe how the incident occurred.

If the incident occurred on a road, please include the road or street you were travelling on, closest intersection, direction of travel (northbound/southbound/eastbound/westbound), and the lane in which you were travelling.
Please describe what happened to cause the damages (e.g. I hit an object on the road/pothole etc).
Were emergency services called/required? (e.g. ambulance, police, tow truck).

NOTE: Retain all written proof (i.e. invoices) of the “Costs Incurred”, as these will be required. Leave blank if you do not have an estimate at this time.

"Claimant" is the person filling out this form

"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.)

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.

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.

The Town of Halton Hills is participating in a program conducted by Local Authority Services (LAS) that provides the digital platform for this form. LAS receives aggregate data in compliance with the Municipal Freedom of Information and Protection of Privacy Act, on insurance claims for the purpose of improving the digital platform and the LAS municipal risk management program.