Bruce County Claim Intake Form

Complete the following details for the claim you are submitting.

Please select Submit to automatically forward your Claim Submission Application

to the Corporate Services Department. All fields are mandatory unless indicated otherwise.

If you have any questions regarding this form, please contact the Corporate

Services Department. Email insurance@brucecounty.on.ca or call 519-881-1291.

Incident/Claim Information

Incident Type

Other Incident Type

Incident Date

MM/DD/YYYY

Hour

Minute

AM/PM

Incident Location

Incident City

Incident Province

Incident Description

Police File Number (if applicable)

Was there damage to personal property?

Was there damage to motor vehicle(s)?

Estimated Damages/Losses ($)

Please insert dollar amount only.

Reporter Details

"Reporter" is the person filling out this form

Are you reporting this incident on behalf of yourself or another person?

Please enter your details in this Reporter Details section.

In the Involved Person Details section below, enter the details of the person(s) for whom you are filling out this form.

Involvement Type

Did you sustain an injury?

First Name

Last Name

Phone

Mobile Phone

Email

Mailing Street

Mailing City

Mailing Province

Mailing Country

Mailing Postal Code

Are you a minor? (under age of majority)

Birthdate

Have you reported this incident to your insurer?

Insurance Company

Claim Number

Did you seek medical attention?

Did you receive care from Emergency Medical Services?

Healthcare Provider's Name

Have you received any other medical aid?

Description of Personal Injuries

Nature(s) of Injury

Select multiple options by holding "ctrl"/"cmd"

Part(s) of Body

Select multiple options by holding "ctrl"/"cmd"

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

IP RecordTypeID

Claimant?

Org RecordTypeID

Did this person sustain an injury?

First Name

Last Name

Phone

Mobile Phone

Email

Mailing Street

Mailing City

Mailing Province

Mailing Country

Mailing Postal Code

Is this person a minor? (under age of majority)

Birthdate

Has this person reported this incident to their insurer?

Insurance Company

Claim Number

Did this person seek medical attention?

Did this person receive care from Emergency Medical Services?

Healthcare Provider's Name

Has this person received any other medical aid?

Description of Personal Injuries

Nature(s) of Injury

Select multiple options by holding "ctrl"/"cmd"

Part(s) of Body

Select multiple options by holding "ctrl"/"cmd"

To add another involved person, please select "Add Another Involved Person" on the bottom-right portion of this section.

Involved Vehicle/Equipment

Note: If you do not know the specific details of the vehicle, please use "N/A"

Ownership

Vehicle/Equipment Make

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

Vehicle/Equipment Model

Vehicle Asset Name

Vehicle/Equipment License Plate Number

Vehicle/Equipment Year

Vehicle/Equipment Type

Vehicle/Equipment Number

Description of Damages

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

Damaged Property

Note: If you do not know the property details, please put "N/A"

Ownership

Property Name/Brief Description

Street Address 1

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

Street Address 2

City

Province

Country

Description of Damages

To add another property, please select "Add Another Property" 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".

Acknowledgement

I confirm that the information provided is true and correct to the best of my

knowledge. I authorize the County of Bruce to use the above information to

process and assess this claim. The collection of personal information on this form is necessary for the administration and management of the County of Bruce’s integrated claims and insurance programs. Information contained on this form will be used by authorized County staff for the above-noted purposes, and may be shared with the County’s insurance provider or any other party as required by law. Questions regarding this collection should be addressed to the County of Bruce, Corporate Services Department.

I agree