Notice of Claim

Please note that all fields marked with a red Asterisk () are mandatory to complete in order to submit this form.

Notice of Collection

This information is collected in accordance with section 32(c) of the Alberta Freedom of Information and Protection of Privacy Act (FOIPP). Personal information is protected under the Alberta FOIPP Act. For further information, please contact:

City of St. Albert's Chief Legislative Officer

5 St.Anne Street
St. Albert, Canada
T8N 3Z9
(780) 459-1705

Collection Consent

Does the City of St. Albert have your consent to collect, use, or disclose your information that is necessary and reasonable for the purposes of processing your claim?

Note: If you select 'No', the City of St. Albert is unable to accept your online form as notice to the City about your claim.

Type of Claim

(Please select all that apply)

Motor Vehicle AccidentBodily InjuryProperty DamageOther

Claimant Information

First Name

Last Name

Address

City

Province

Postal Code

Phone

Incident Details

Date and Time

AM/PM

TimeFormula

Incident Address

Incident City

Incident Province

Incident Postal Code

Please provide as many incident details as possible in the description below.

NOTE: All reasonable steps must be taken to mitigate your loss while preserving any evidence for investigation. This could include physical evidence, photos, recorded documentation, video, and witness statements. Failure to mitigate your loss could result in additional damages that may not be covered while failure to preserve evidence could cause a delay in the handling of your claim.

Incident Description

An "Involved Person" is an individual who is/may be involved with the claim/incident (directly or indirectly) being reported. (Examples include a City Employee or Contractor.)

Do you wish to add Involved Persons to this report?

Involved Person Details

Involvement Type

Record Type ID

Organization ID

Other Involvement Type (Please Specify)

City Department

Start to enter the Department name and then select it from the displayed list

Department ID

First Name

Last Name

Company Name

Phone

To add another involved person, please select "Add Another Involved Person" below.

Vehicle Damage

Year

Make

Model

Plate Number

Vehicle Name

Description of Vehicle Damages

List all damages to vehicle as well as any other damages or expenses being claimed (vehicle rental, storage, tow, etc)

Estimated Vehicle Damage Claim Amount ($)

Please enter numbers and decimals only (e.g. 500, 375.60)

To add another vehicle, please select "Add Another Vehicle" below.

Property Damage (Non-Vehicle)

Property Description (e.g. "cell phone")

Property Age (years)

Property Original Cost ($)

Attach original receipt below, if available

Property Address (if applicable)

Asset Record Type

Property City

Property Province

Property Postal Code

Description of Property Damages

List all damages to vehicle as well as any other damages or expenses being claimed (vehicle rental, storage, tow, etc)

Estimated Property Damage Claim Amount ($)

Please enter numbers and decimals only (e.g. 500, 375.60)

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

Personal Injury

Were you on the job at the time of injury?

Employer

Description of Personal Injuries

List all damages to vehicle as well as any other damages or expenses being claimed (vehicle rental, storage, tow, etc)

Estimated Personal Injury Claim Amount ($)

Please enter numbers and decimals only (e.g. 500, 375.60)

Insurance Information

Do you have an insurance policy and/or warranty under which damages may be recovered?

Was a claim submitted to your insurance company for damages?

Insurance Company

Claim Number

Adjuster First Name

Adjuster Last Name

Adjuster Phone

Adjuster Email

Was a police report filed?

Report Number

Attachments

The Claimant is required to provide all documents to support their claim. Failure to provide complete information and/or supporting documents may delay investigation of your claim.

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.

File Upload

To add more than one attachment, select "Add Another Attachment". To remove the additional File Upload option, select "Remove".

Please Note: This form is for information purposes only and its receipt in no way infers acceptance of any responsibility by this Municipality for the stated damages. Be aware that there are notice periods for providing the City with notice of certain types of claims and limitation periods in respect of all claims. Further, if you do not commence legal action to advance your claim within the time periods proscribed by the Limitations Act of Alberta, the City and its employees will be entitled to immunity from liability.

I solemnly swear that I am the owner/occupier of the damaged property, or the injured party, and the foregoing is a correct and accurate state as to the damages incurred. By checking this box, I am electronically signing this claim form.

I agree

Questions?

Contact: Strategic Services (Insurance and Claims)

Phone: (780-418-6003)
Email: insurance@stalbert.ca