City of Brantford Notice of Claim

This notice of Claim is for information only and does not infer acceptance of liability by the City of Brantford.

Notice of Collection of Personal Information: The personal information collected on this form is collected under the authority of sections 279(1) and 10(1) of the Municipal Act, 2001 as amended, and will be used to contact claimants to process a claim filed against the municipality.

Questions about this collection should be directed to the Claims & Insurance Analyst, 58 Dalhousie Street
Brantford, ON, N3T 2J2 (519)759-4150

Claim Information

Incident Type

Incident Date/Time

AM/PM

Incident Address

Street address or nearest intersection

Incident City

Incident Province

Incident Country

Postal Code

Incident Description (And why you believe that the City of Brantford if responsible.)

Address or nearest intersection, direction of travel, lane of traffic (i.e. curb lane), Facility name and location.

Did the incident occur as a result of work being performed by a contractor?

Name of Contractor

Police File Number

Estimated Damages/Losses ($)

Please insert dollar amount only.

To substantiate your claim, provide original purchase receipts, repair estimates, photos, or other evidence.

Did you report the incident to the City prior to completing this form?

City Employee Name and Department

Name and Department

Reporter Details

"Reporter" is the person filling out this form

Involvement Type

Did you sustain any injuries?

First Name

Last Name

Phone

Mobile Phone

Mailing Street

Mailing City

Mailing Province/State

Mailing Country

Postal Code/Zip Code

Did you seek Medical Attention immediately following the incident?

NOTE: All persons have the right to refuse treatment. A person who is 16 years or older or who is presumed to be capable of giving or refusing consent in connection with his or her own personal care.

Health care provider's name

Did you receive care from Emergency Medical Services?

If yes, please add the contact(s), badge #, occurrence #, contact information and file number(s) in an INVOLVED PERSON section below.

Did you receive any other medical aid?

Description of Personal Injuries

Part of Body

Select multiple by holding "ctrl".

Nature of Injury

Select multiple by holding "ctrl".

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

Did this person sustain an injury?

First Name

Last Name

Phone

Mobile Phone

Mailing Street

Mailing City

Mailing State/Province

Mailing Country

Mailing Postal Code/Zip Code

Is this person a minor? (under 16)

If this person is injured/involved in this incident, a parent/guardian must be present or called. In the Involved Persons section, record the name of who was contacted and the time contacted.

Did this person seek Medical Attention immediately following the incident?

NOTE: All persons have the right to refuse treatment. A person who is 16 years or older or who is presumed to be capable of giving or refusing consent in connection with his or her own personal care.

Health care provider's name

Has this person received any other medical aid?

Did this person receive care from Emergency Medical Services?

If yes, please click Add Another Involved Person below to add the contact(s), badge #, occurrence #, contact information, and file number(s).

Call Phone Number from Ambulance Call Report

Description of Personal Injuries

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 Involved Person" on the bottom-right portion of this section. This will open another section where information can inserted. If not required, please ignore.

Resident Owned Involved Vehicle

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

Vehicle Make

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

Vehicle Model

Vehicle Name

Vehicle License Plate Number

Vehicle Year

Vehicle Type

Description of Damages

To add another vehicle, please select "Add Another Vehicle" 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 Attachment". To remove the additional file upload option, select "Remove".

Declaration

This notice of Claim is for information only and does not infer acceptance of liability by the City of Brantford.

Personal information on this form is collected under the authority of Section 10(1) of the Municipal Act, 2001, S.O. 2001, c.25, as amended and will be used to contact you concerning your service request/inquiry to the City of Brantford. Questions about this collection should be directed to:

City of Brantford Customer Contact Centre

Brantford City Hall

58 Dalhousie Street, Brantford, Ontario N3T 2J2

Telephone: 519-759-4150

Email: claims@brantford.ca

By submitting this form, you confirm that information in this document is correct to your knowledge.

I agree