Town of Newmarket Claim Form 

Personal Information on this form is collected under the authority of the Municipal Act 2001, C.25 and will be used to process your claim with the Town of Newmarket. Questions about this collection may be directed to the Claims & Risk Analyst at: Town of Newmarket Phone: 905-895-5193 Office of the Town Clerk - Legislative Services 395 Mulock Drive Email: info@newmarket.ca P.O. Box 328 STN Main Newmarket, Ontario L3Y 4X7 Notices should be submitted to the Town within 10 days of the incident. A 2 year limitation period to submit a claim action will apply as per Section 4 of the Limitations Act, 2002 S.O. 2002, Chapter 24, Schedule B. All claims submitted are to be made in writing as per the Municipal Act 2001, and submitted to the Office of the Town Clerk. Completing this form online is equivalent to submitting it in writing. The electronic submission of this Form is not an admission of liability or waiver of rights by the Town. Note: All fields with a red asterisk (*) must be complete to submit this form.

Personal Information

Select "Myself" if you are the Claimant completing this form.

You are a representative for the claimant and will be the main point of contact for this claim. Provide your details below.


















e.g. chiropractor, massage therapist, physiotherapist, family doctor...


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

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



"Involved Person" is an individual who is involved with the incident. Examples include the claimant, legal representative, adjuster, witness etc.

Involved Person Details

















If you select “Yes,” the page will automatically show additional fields about your injury and the medical professionals you consulted






e.g. chiropractor, massage therapist, physiotherapist, family doctor...


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

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. 
Incident Information






If you do not know the exact time, provide an approximate time the incident occurred.


If you do not know the exact address, provide the closest intersection or point of reference.



Explain What Happened.





Note: Pursuant to s. 199 (1) of the Highway Traffic Act, R.S.O 1990, c. H. 8, individuals who are involved, either directly or indirectly, in a vehicle-related accident that results in personal injuries or property damage in excess of $5,000.00 must report the accident to the nearest police officer forthwith.

If York Regional Police was called or involved in the incident, provide the occurrence number.




Please insert dollar amount only. You must upload all written proof (e.g. invoices paid) as part of your claim submission
Involved Vehicle/Equipment

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


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







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"








To add another property, please select "Add Another Property" on the bottom-right portion of this section.
Attachments

Upload all relevant documents as part of your claim submission. Examples of relevant documentation includes: invoices, estimates, photographs, and medical reports.

Photographs of the location where the loss occurred should be in colour. If the photograph is of a

location where an injury occurred, mark the exact location on the photograph with an X.

Ensure to make copies of all documentation submitted with your claim, as these will not be returned to you.


To add more than one attachment, select "Add Another Attachment". To remove the additional file upload option, select "Remove".
Declaration and Statement of Acknowledgement

The information provided is true and correct to the best of my knowledge. I understand that submitting false statements and/or documentation is a form of fraud and is illegal. I acknowledge that fraudulent claims cost taxpayers, and that claims that are determined to be made fraudulently will be prosecuted to the full extent of the law.


I hereby give consent to the Town of Newmarket to collect, use or disclose my information that is necessary and reasonable to process and assess this claim.

 

I accept that the Town may disclose my personal information and the details of my claim to the Town’s insurance adjuster and/or to those involved in the resulting claim resolution, including but not limited to legal counsel, or third parties that may be responsible for losses claimed, or any other party as required by law.

 

Once you click the submit button below, you will receive an acknowledgement email from success+newmarket@clearrisk.com. Check your email’s junk mail and spam mailboxes for this email. If you do not receive an acknowledgement email within 24 hours, this means the Town did not receive your claim submission.

 

I have read, acknowledge and understand the consequences and agree with the statements above.


You must agree with this declaration and statement of acknowledgement to submit the claim.