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Personal information on this form is collected under the authority of the Municipal Act 2001, S.O. 2001, C.25, for the purpose of handling your claim with the City of Greater Sudbury by City staff and/or its agent(s). Questions about the collection of this personal information should be directed to the Risk Management Support Assistant, City of Greater Sudbury, PO Box 5000 Stn A, 200 Brady Street, Sudbury, Ontario, P3A 5P3 or by calling 705-674-4455, extension 4269.*
Your Information








Claim Information


HH:MM pm or HH:MM am (Please use 12-hour format)


NOTE: THERE IS A 10 DAY NOTICE FOR PROVIDING THE CITY WITH NOTICE OF CERTAIN TYPES OF CLAIMS AND A TWO YEARS LIMITATION period for bringing an action in respect to all claims. 
Vehicle Damage


*For most claims, the City must receive this claim form within 10 days of your damage for it to be considered.  





List the lane of travel, address, intersection, any nearby store or landmark to identify the exact location of your accident. Example: In the right lane, on the Kingsway, heading west, and directly in front of ‘ABC’ Restaurant.

Home or Property Damage





Injury




Attachments (Please attach photos, Police report, invoices or additional information in support of your claim






Consent
I understand that the use of profanity, abuse, threat or cyber bullying may cause the City of Greater Sudbury staff and/or the independent adjuster 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 directed solely to the independent adjuster assigned to the claim. Claims involving matters of non-repair of roads or sidewalks must be reported to the City within 10 days of the incident. 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.