City of Guelph Claim Form

Incident/Claim Information

To request this information in an accessible format, contact:

Risk Management Specialist, Legal & Court Services

dwain.manning@guelph.ca

519-822-1260 x 2230; TTY 519-826-9771
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/State

Mailing Country

Mailing Zip/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

Did this person sustain an injury?

First Name

Last Name

Phone

Mobile Phone

Email

Mailing Street

Mailing City

Mailing Province/State

Mailing Country

Mailing Zip/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/State

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".

Declaration

Collection of Personal Information

Personal information is being collected and will be used for the purpose of investigating insurance claims.
Personal information, as defined by Section 2 of the Municipal Freedom of Information and Protection of Privacy Act (MFIPPA), is collected under the authority of the Municipal Act, 2001, and in accordance with the provisions of MFIPPA.

If you have questions about submitting a claim for injury or damage please contact City of Guelph, Risk Management at claims@guelph.ca.

NOTE: By submitting this form, you confirm that the information in this document is correct to the best of your knowledge.
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