Claim Intake Form

Claim Information

Accident Type

Other Accident Type

Accident Date/Time

AM/PM

Accident Address

Accident City

Accident Province

Accident Country

Closest Intersection

Accident Description

Police File Number (if applicable)

Was there damage to personal property?

Was there damage to motor vehicle(s)?

Reporter Details

"Reporter" is the person filling out this form

Involvement Type

Did you sustain an injury?

First Name

Last Name

Phone

Mailing Street

Mailing City

Mailing Province/State

Mailing Country

Mailing Zip/Postal Code

Have you reported this accident to your insurer?

Insurance Company

Policy Number

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

Do you wish to add Involved Persons?

"Involved Person" is an individual who is/may be involved with the claim/accident (directly or indirectly) being reported. (Examples include the claimant, witness to the accident, lawyer, property manager, employees, etc.)

Involved Person Details

Involvement Type

Did this person sustain an injury?

First Name

Last Name

Phone

Mailing Street

Mailing City

Mailing Province/State

Mailing Country

Mailing Zip/Postal Code

Has this person reported this accident to their insurer?

Insurance Company

Policy Number

Claim Number

Did this person seek medical attention?

Did this person receive care from Emergency Medical Services?

Healthcare Provider's Name

Call Phone Number from Ambulance Call Report

Has this person received any other medical aid?

Description of Personal Injuries

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

Estimated Damages/Losses ($)

Please insert dollar amount only.

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"

Property Name/Brief Description

Street Address 1

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

Street Address 2

City

Province/State

Country

Estimated Damages/Losses ($)

Please insert dollar amount only.

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 Markham, Risk Management at claims@markham.ca.

NOTE: If you do not agree, the Markham is unable to accept your on-line form as notice to the City about your accident.

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

I agree