THE CORPORATION OF THE MUNICIPALITY OF CHATHAM-KENTLEGAL LIABILITY FORM

THE CORPORATION OF THE MUNICIPALITY OF CHATHAM-KENT
LEGAL LIABILITY FORM

The Municipality of Chatham-Kent will not be held responsible for your losses unless you can provide evidence that the Municipality committed a negligent act or omission which resulted in a loss.

We suggest that in all cases of loss or damage you contact your insurance company or broker. Depending on the type of property damaged, and the insurance policy you purchased, you may be eligible for compensation from your insurance company.

Like most Canadian municipalities, the Municipality of Chatham-Kent only compensates when it is legally obligated to do so. This approach helps to reduce costs for the taxpaying public who bear the cost of these claims.

Claimant Details

First Name

Last Name

Phone

Street Address

City

Province

Are you reporting this claim on behalf of another individual?

Submitter First Name

Submitter Last Name

Submitter Email

Submitter Phone

Incident/Claim Details

Date and Time Incident Occurred

A/P

AM/PM

Did the incident occur at a specific address or an approximate location?

Incident Location

(approximate address or closest intersection)

Incident Address

Incident City

Incident Province

Claimant Insurance Company Name

Claimant Insurance Broker Name

Claimant Insurance Policy Number

Name of Any Contractor Involved (If Known)

Detailed Description of the Incident

Detailed Description of Damage or Injury Caused

Describe What Steps Were Taken to Prevent the Incident From Occurring

Attachments and Files

Please provide photos of the area where the loss occurred if you are able.

Please provide any quotes/invoices you may have if you are making a claim for property damage.

Attachment 01

Attachment 02

Attachment 03

Attachment 04

Are there additional attachments to be submitted?

Attachment 05

Attachment 06

Attachment 07

Attachment 08

Attachment 09

Attachment 10

Attachment 11

Attachment 12

Contact Information